Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty.

Antibiotic-impregnated cement is used frequently in revision procedures of infected total hip and knee arthroplasties. Local antibiotic treatment is as effective as the use of systemic antibiotics. The purpose of such treatment is to provide high tissue concentrations of antibiotics and minimize systemic toxicity, especially nephrotoxicity. Though antibiotic-impregnated cement is considered safe in terms of nephrotoxicity, two cases that have implicated aminoglycoside-impregnated cement in acute renal failure (ARF) after surgery for an infected total knee arthroplasty (TKA) have been reported [Curtis et al. 2005, Van Raaij et al. 2002]. Two more cases of postoperative ARF after use of combined tobramycin- plus vancomycin-impregnated cement, this time in total hip arthroplasty, have been recently reported [Patrick et al. 2006]. We report a case of ARF in a 61-year-old patient with a history of diabetes mellitus and hypertension after treatment of a febrile infection of a TKA with combined gentamicin- plus vancomycin-impregnated cement. The ARF could not sufficiently be attributed to other causes and though serum concentrations of antibiotics obtained from the 8th postoperative day and thereafter were far below the trough levels associated with nephrotoxicity, gentamicin and vancomycin seem to have contributed significantly to ARF in our case.

The pathogenetic influence of I-parathyroid hormone on slipped capital femoral epiphysis. Towards a new etiologic approach?

The displacement of the femoral head along the upper femoral physis that occurs during adolescence or slipped capital femoral epiphysis (SCFE) is not a very common traumatic entity. Ever since Muller1 first described it in 1888, its symptoms, clinical manifestations, diagnosis, treatment and complications have been thoroughly described and studied. Nevertheless little progress has been accomplished as far as its etiology is concerned. In order to assess the potential pathologic influence of any parathyroid hormone (PTH) disturbances on the development of SCFE, we conducted a prospective clinical study with 14 patients, 7 boys and 7 girls (16 hips), suffering from SCFE (Group A). Another 5 patients who had been treated for SCFE a few years before the study, were used as a control group (Group B). We measured the level of I-PTH along with serum calcium (Ca) and phosphorus (P) levels. Furthermore, we checked all the necessary anthropometric characteristics of the patients (i.e., age, height, weight and sexual maturation). Each patient of Group A was categorized from grade I to grade V according to the progress of the slipping. The results showed an increased incidence of serum PTH level abnormalities (both decrease and increase) in Group A while Group B patients had normal results. The detected I-PTH serum level abnormalities were not in any pattern related to the Ca and P serum levels. We believe that a temporary parathyroid hormone disorder during the early years of adolescence may play a potentially significant role (along with other etiologic factors) in the development of SCFE.

Expression and regulation of parathyroid hormone-related peptide in normal and malignant melanocytes.

We examined parathyroid hormone-related peptide (PTHrP) production and regulation in both normal human melanocytes and in a human amelanotic melanoma cell line (A375). Northern blot and immunocytochemical analysis demonstrated that both cultured A375 cells and normal human melanocytes express PTHrP, but A375 cells expressed much higher levels of the peptide. PTHrP secretory rate increased at least 10-fold after treatment with 10% fetal bovine serum (100.2 +/- 2.8 pmol/10(6) cells vs. basal <15 pmol/10(6) cells) in proliferating A375 cells but only twofold in confluent cells. Treatment of A375 cells with increasing concentrations of 1, 25-dihydroxyvitamin D(3) [1,25-(OH)(2)D(3)] or its low-calcemic analog EB-1089 revealed that EB-1089 was 10-fold more potent than 1, 25-(OH)(2)D(3) on inhibition of both cell proliferation and PTHrP expression. Furthermore, inoculation of A375 cells into the mammary fat pad of female severe combined immunodeficiency mice resulted in the development of hypercalcemia and elevated concentrations of plasma immunoreactive PTHrP in the absence of detectable skeletal metastases. Our study, therefore, demonstrates a stepwise increase in PTHrP expression when cells progress from normal to malignant phenotype and suggests that EB-1089 should be further evaluated as a therapeutic agent in human melanoma.

Surgical treatment of unstable diaphyseal both-bone forearm fractures in children with single fixation of the radius.

We retrospectively reviewed the result from 50 children (5 to 14 years; mean age 11 years) with unstable diaphyseal forearm fractures involving both the radius and ulna, for which closed reduction has been unsuccessful, and so were treated with open reduction and internal fixation of the radius only. The rationale of this treatment is to stabilize the radius as it is this bone which has the more complicated function of the two forearm bones. After anatomical reduction and fixation of the radius the ulnar fracture had a better alignment. In this series the functional and the anatomical results in all children at a mean follow up of 4 years (range 1 to 10 years) were excellent.

The vitamin D analogue EB 1089 prevents skeletal metastasis and prolongs survival time in nude mice transplanted with human breast cancer cells.

1,25-Dihydroxyvitamin D has potent antiproliferative and anti-invasive properties in vitro in cancer cells. However, its calcemic effect in vivo limits its therapeutic applications. Here, we report the efficacy of EB 1089, a low calcemic analogue of vitamin D, on the development of osteolytic bone metastases after intracardiac injection of the human breast cancer cell line MDA-MB-231 in nude mice. Animals injected with tumor cells were implanted simultaneously with osmotic minipumps containing either EB 1089 or vehicle. Both groups remained normocalcemic for the duration of the experiment. The total number of bone metastases, the mean surface area of osteolytic lesions, and tumor burden within bone per animal were markedly decreased in EB1089-treated mice. Furthermore, longitudinal analysis revealed that mice treated with EB1089 displayed a marked increase in survival and developed fewer bone lesions and less hind limb paralysis over time as compared with untreated animals. These results suggest that EB1089 may be beneficial in the prevention of metastatic bone lesions associated with human breast cancer.

Reversal of hypercalcemia with the vitamin D analogue EB1089 in a human model of squamous cancer.

EB1089, an analogue of 1,25 dihydroxyvitamin D with low calcemic activity is a potent inhibitor of parathyroid hormone-related peptide (PTHRP) production in vitro. The purpose of the present study was to determine whether EB1089 could reverse established hypercalcemia in BALB C nude mice implanted s.c. with a human epithelial cancer previously shown to produce high levels of PTHRP in vitro. Total plasma calcium was monitored before and after tumor development and increased steadily when the tumor reached > or =0.5 cm3. When total calcium was 22.85 mmol/liter, animals were treated with a constant infusion of EB1089 or vehicle alone for a period of 2 weeks. A significant and sustained reduction of plasma calcium from 3.2+/-0.1 to 2.7+/-0.08 (P < 0.01) mmol/liter was observed during infusion with EB1089. In contrast, calcium levels in vehicle-treated animals continued to rise during the infusion period. Tumor growth velocity also slowed significantly after the administration of EB1089 as compared with vehicle-treated animals. Plasma PTHRP levels measured at the end of the 2 weeks' infusion period were significantly lower in animals treated with EB1089 as compared with animals treated with vehicle alone (44+/-8 pg/ml versus 194+/-35 pg/ml, P < 0.001). These results, therefore, demonstrate that EB1089 can reverse established hypercalcemia in a human model of squamous cancer.

Changing patterns in advanced gastric carcinoma.

A retrospective study on patients with gastric cancer during the periods 1984-88 (n = 63 patients) and 1989-93 (n = 59 patients) was made. The aim of the study was to assess any changing patterns in tumour distribution, surgical management and survival during the two periods. When the diagnosis was made, the majority of tumours were advanced: 58 were stage IV and 21 were stage IIIB, with 43 tumours at earlier stages. The incidence of proximally located gastric adenocarcinomas increased from 15.9 to 27.1%, while the incidence of carcinomas located in the body decreased from 34.9 to 23.7%. The majority of patients underwent conservative gastrectomy. The proportion of proximal gastrectomies increased from 3.2 to 15.3 per cent (p = 0.02), whereas the proportion of combined resection of adjacent organs decreased from 38.1 to 22.0 per cent (p = 0.04). Perioperative mortality rate decreased from 17.5 to 1.7 per cent (p = 0.003). Prognosis remained unchanged in the two periods; overall 5-year survival is calculated as 12 per cent.

Supracondylar humeral osteotomy in children with severe posttraumatic cubitus varus deformity.

The authors report the results of corrective osteotomy of the humerus in 11 children with severe posttraumatic cubitus varus deformity. The average carrying angle on the affected side was -24.4 degrees, and there was an average internal rotation deformity of the distal humerus of 22 degrees. Flexion and extension of the injured elbow were severely limited. A supracondylar lateral wedge osteotomy of the humerus was performed keeping the medial cortex intact. Two K-wires served as levers to correct the angular and rotational deformity of the elbow and then as fixation material to hold the osteotomy fragments. Postoperatively we immobilized the elbows in 90 degrees flexion for 3 to 4 weeks. There was no loss of the postoperative osteotomy alignment in most cases. Recurrence of mild varus deformity (-5 degrees and -7 degrees) occurred in only two patients. At the end of the follow-up we observed excellent results in 9 patients with an average carrying angle of 7.2 degrees (range 5-10 degrees).

Reconstruction of residual deformities of the hip. A new surgical option.

Shortening of the femoral neck and relative overgrowth of the greater trochanter are the main problems after avascular necrosis of the capital femoral epiphysis. A new type of femoral osteotomy was performed in 16 patients to lengthen the femoral neck, improve the biomechanics of the hip joint with a better congruity of the head, and to restore the leg length discrepancy. Clinical and radiologic followup showed good results in all the patients after a mean time of 4.3 years. Relief of pain, a negative Trendelenburg sign, and improvement of hip movements, particularly abduction, were the most significant short term results.

Parathyroid-hormone-related peptide in hematologic malignancies.

PURPOSE: To determine whether parathyroid-hormone-related peptide (PTHRP) is an important pathogenetic mediator of hypercalcemia in patients with hematologic malignancies. PATIENTS AND METHODS: We conducted a cohort analytic study in 76 consecutive patients with non-Hodgkin's lymphoma (NHL), Hodgkin's disease, multiple myeloma, and Waldenstrom's macroglobulinemia, 14 of which were hypercalcemic. Thirty normal subjects served as a control group. RESULTS: Using the NH2 -terminal radioimmunoassay, PTHRP concentrations in heavy controls were undetectable (<7.5 pmol equivalents of PTHRP [fragment 1-34] per liter). The majority of hypercalcemic patients (8/14) had non-Hodgkin's lymphoma, and 62.5% of these (5/8) had significant elevations of circulating PTHRP concentrations (mean 70.5 +/- 38.5 pmol equivalents of PTHRP per liter) (P <0.01). In non-Hodgkin's lymphoma, 11 of 30 patients with advanced disease (stage IV) had elevated PTHRP concentrations, and of these, 8 of 11 had high-grade pathology. In contrast, only 3 or 21 patients with less advanced disease (stage I to III) had elevated PTHRP concentrations. In 4 NHL patients with less advance PTHRP concentrations sampled prior to cytotoxic chemotherapy, tumor response was associated with a decrease in PTHRP. Concomitant suppression of 1,25(OH)2D3 concentrations was observed in 66% of hypercalcemic patients with non-Hodgkin's lymphoma. CONCLUSIONS: These results suggest that PTHRP may be an important pathogenetic factor in the development of hypercalcemia in hematologic malignancies, notably in non-Hodgkin's lymphoma.

Cystic angiomatosis of bone: a case report.

Diffuse skeletal cystic angiomatosis is an extremely rare disorder that has not previously been reported in detail in the dental literature. This case report deals with the oral manifestations in a 10-year-old boy. Clinical, radiographic, and computed tomographic examinations showed hyperplasia of the right side of the face. The computed tomographic imaging studies revealed the extent of the jawbone lesions and the adjacent hyperplastic soft tissues. The histologic appearance of the lesions, the course of the disease, and the differential diagnosis are discussed.

Vitamin D analogs: new therapeutic agents for the treatment of squamous cancer and its associated hypercalcemia.

We have examined the in vitro effects of 1,25 dihydroxy-vitamin D3 [1,25(OH)2D3] and of two side-chain modified analogs of 1,25(OH)2D3 (EB1089 and MC903) on cell growth and parathyroid hormone related peptide (PTHRP) production in immortalized (HPK1A) and neoplastic (HPK1A-ras) keratinocytes. Cell proliferation was strongly inhibited by 1,25(OH)2D3 and its analogs in HPK1A cells, and in this system EB1089 was 10-100 times more potent than 1,25(OH)2D3 or MC903. A similar effect on cell proliferation was observed in HPK1A-ras cells; however, 10-fold higher concentrations of 1,25(OH)2D3 or its analogs were required. We also observed a strong and dose-dependent inhibitory effect of these compounds on PTHRP secretion and gene expression. In both immortalized and neoplastic keratinocytes, EB1089 was 10-100 times more potent than 1,25(OH)2D3 or MC903 on inhibiting PTHRP production. However, although effective in HPK1A-ras cells, 10-fold higher concentrations of 1,25(OH)2D3 or its analogs were required to produce similar actions in this neoplastic model. These studies therefore demonstrate that a 1,25(OH)2D3 analog with low calcemic potency in vivo (EB1089) can inhibit keratinocyte proliferation and PTHRP production by such cells with greater potency than 1,25(OH)2D3. The observed effects of such analogs in neoplastic keratinocytes predicts their potential usefulness in vivo in inhibiting squamous cancer growth and its associated hypercalcemia.

'Natural' healing of hip fractures in childhood.

Twenty intracapsular fractures of the femur in children below 14 years of age were reviewed. Gentle reduction was performed successfully in the displaced fractures. Close apposition of fracture fragments was maintained in all cases with skeletal traction for a time depending on the patient's age, the displacement and the appearance of bridging callus along the medial cortex of the femoral neck. Periosteal healing was evident in the displaced fractures, even in cases of severe ischaemic necrosis. This paper presents this phenomenon of initial external callus repair, not previously reported in the literature, which indicates the existence of functional periosteum of the femoral neck in children.

[Proximal epiphyseal separation of the femur in the newborn: early ultrasonic diagnosis]. / Décollement épiphysaire proximal du fémur chez le nouveau-né: diagnostic précoce par échographie.

INTRODUCTION: Obstetrical separation of the proximal femoral epiphysis at birth is rare. Most of these fractures are associated with complicated deliveries. MATERIAL AND METHODS: Our patient was admitted on the first day after birth. He was born by caesarean section due to a breech presentation. The clinical examination revealed << pseudoparalysis >> of the left lower extremity. Laboratory studies were within normal limits. RESULTS: Roetgenograms showed a superolateral displacement of the proximal femur with normal acetabular development. An ultrasound examination revealed a normal position for the left femoral head within the acetabulum and no joint effusion. This excluded the possible diagnosis of septic or congenital dislocation of the hip and confirmed the diagnosis of traumatic epiphyseal separation. CONCLUSION: Recognition of this rare injury by using ultrasound may allow early diagnosis and treatment, thus preventing permanent deformities.

[Supracondylar femoral fractures in children before the age of walking]. / Fractures supra-condyliennes du fémur de l'enfant avant l'âge de la marche.

Supracondylar femoral fractures were found, in this report, to be the most common traumatic lesion in the healthy, pre-walking age infant. Diagnosis of such cases which display no longer a rare occurrence, requires accurate x-ray films on two levels, because incomplete fractures may be easily overlooked. Awareness of the normal development of motor function within the first year of life is of great importance to prevent injuries to the immature musculoskeletal system before the beginning of voluntary walking. The acquisition of motor skills was not interrupted and limb length discrepancy was not noted in any of our patients.

Dislocation of the elbow joint associated with fracture of the radial neck in children.

We describe two cases of fracture of the radial neck associated with posterolateral dislocation of the elbow. The purpose of this report is to describe the relatively good functional result that can be achieved by a successful closed reduction of this severe injury.

[Infantile cortical hyperostosis. A case and review of the literature]. / Hyperostose corticale infantile. Un cas et revue de la littérature.

The present report describes an infant with the clinical, radiological and histological features of infantile cortical hyperostosis. Besides the solitary location to the patient's right scapula, the persistence of the radiographic changes of the disease for more than two years is also emphasized in this paper. The disease typically pursued a benign course and neither x-ray findings nor long-term complications were noted 14 years later.

Aneurysmal bone cyst: a preliminary report on a new surgical approach.

Aneurysmal bone cyst is a relatively uncommon bone tumor. Six children treated between February 1985 and May 1987 with an operative approach involving insertion of several Kirschner pins across the tumor area are reviewed. Postoperatively, pain relief and varied healing of the lesion was noted radiologically. We conclude that it is worthwhile to consider insertion of Kirschner pins as a first step in treatment.

[Acute hematogenous osteomyelitis of the patella. Apropos of 3 cases]. / Ostéomyélite hématogène aiguë de la rotule. A propos de 3 cas.

Three cases of acute haemotagenous osteomyelitis of the patella in children less than or equal to 9 years of age were reviewed. The purpose of this paper is to report these cases because of the extreme rarity of the location and the direct relationship of blood supply to this sesamoid bone with the involved areas. The treatment followed was surgical and the clinical and radiological results appear to be excellent after 4.8 and 12 years respectively.

Monteggia-type elbow fractures in childhood.

In an analysis of 29 cases of three different Monteggia-type fractures in children, the mechanism of injury was a hyperpronation force on the extended elbow. The follow-up period ranged from one to three years with a mean of 18 months. Closed reduction of these fractures was always difficult to maintain because the lesions are unstable. Closed reduction was successful in 25 of the 29 cases and open reduction was required in four. A slight residual dorsal angulation remained in 18 cases with fracture of both bones of the forearm, but healing in this position was acceptable.