The management of segmental bone loss associated with forearm fractures

Eighteen fractures of one or both bones of the forearm, including fourteen with segmental defects, were treated with an interposed corticocancellous iliac-bone graft. A plate and screws were used to fix the fracture fragments and graft. The technique allowed early motion of the extremity. Good results were achieved in all but six of the patients. The one poor result with non-union and five others with limited motion were related primarily to infection.     

Reconstruction of the loss of bone substance of the forearm by cubitalization of the radius (one bone forearm). Apropos of 6 cases

Extensive forearm bone loss, whatever its etiology, presents a difficult reconstruction problem. This is mainly the case in the presence of lesions of the interosseous membrane associated with the radio-ulnar joint. When preservation of forearm rotation is not possible, cubitalization of the radius and reconstruction of the forearm by creation of a "one bone forearm" seems to be an excellent salvage technique both functionally and cosmetically. Our experience concerns six clinical cases; two of these cases are original and give the authors the opportunity to describe a new reconstructive technique of the distal humerus and elbow by vascularized transfer of the radius onto the radial artery (with a cutaneo-osseous transfer in one case). The etiology of the bone defect included severe trauma in three cases, and a Volkman's syndrome complicated by osteomyelitis in one case. Two cases represent an original technique of reconstruction of the distal humerus by a vascularised transfer of the radius onto the radial artery. Forearm reconstruction is performed by cubitalization of the radius. The etiology was traumatic in one case and neoplastic in another, and a cutaneo-osseous transfer was performed in the latter case. In this difficult problem of bone reconstruction, a favorable functional and cosmetic result was obtained in our series.     

Surgical treatment of metastatic long bone disease

A retrospective study of the results of operative treatment of 60 long bones secondaries in 46 patients was carried out. The mean period of follow-up was 10 months. The most common primary in this study was carcinoma of the breast (28.2%), followed by carcinoma of the lung (21.7%) and unknown primary (10.9%). Three groups of patients were studied--pathological fracture group, prophylactic fixation group and a mixed group. In the pathological fracture group, 70% of patients achieved good to excellent pain relief and 60.9% was able to walk with or without walking aids. In the prophylactic group, all the patients achieved good to excellent pain relief and 60% were able to ambulate with or without walking aids. In the mixed group, all the patients achieved good to excellent pain relief and 66.6% of the patients were able to walk with aids. The operative mortality in both the pathological fracture group and prophylactic fixation group was 10% and 33.3% in the mixed group. Multiple internal fixation performed at one operative session was associated with high operative mortality (50%).     

Prevention of post-oophorectomy bone loss with Tibolone

The organic symptoms and results of coagulation tests of disseminated intravascular coagulopathy (DIC) in 17 patients with infection were compared with those in 12 patients with malignancy. The infectious diseases were mainly sepsis and pneumonia, and the malignancy was mainly lung cancer. The mean antithrombin III (AT III) before treatment was 54% in infection and 68% in malignancy, and the AT III values improved after administration of 1500 U of AT III concentrates per day. The mean thrombin-antithrombin complex level decreased from 22 ng/ml to 9 ng/ml after the treatment in infection, but it increased in malignancy. There were no differences in DIC scores between infection and malignancy before treatment; however, the scores were significantly more improved in infection than in malignancy after treatment (p < 0.05). The fibrin/fibrinogen degradation product level, platelet count, and fibronectin level were also significantly more improved in infection than in malignancy. This better response to treatment in infection than in malignancy is probably due to eradication of the causative organisms by antibiotics in infection. These data suggest that therapy against both DIC and the underlying disease is crucial for successful treatment.     

Prediction of bone loss in patients with primary hyperparathyroidism using quantitative bone SPECT

Bone loss is a major complication of primary hyperparathyroidism (PHPT), and it has significant implications in the treatment of this disease. Bone turnover was measured in patients with PHPT, using quantitative bone SPECT (QBS), to determine if the rate of bone loss could be predicted before a significant decrease in bone mass occurs. METHODS: Forty-six patients were included in the study. QBS and bone mineral density (BMD) of the lumbar spine (LS) and femoral neck (FN) were done at baseline. The percent deviation of QBS in patients with PHPT from the values in normal matched controls was calculated. BMD was measured again after a mean of 17.5 mo in 38 patients, and in 29 patients a repeat BMD study was done after a mean of 41.4 mo. The change in BMD in patients with high and normal QBS values was compared using the nonparametric Mann-Whitney test. Regression analysis tested the correlation between baseline QBS values and BMD changes over time. RESULTS: For the FN, there was a statistically significant difference in the BMD change between patients with high and normal QBS values for short-term follow-up (-2.82%+/-4.80% versus 1.45%+/-4.67%, p < 0.05) and for long-term follow-up (-3.53%+/-5.34% versus 0.92%+/-2.40, p < 0.02). There was a negative correlation in the FN, r=-0.48 between QBS values and the percentage of change in BMD. There was no significant difference between the percentage of change in BMD in the LS in patients with high and normal QBS values for either short- or long-term follow-up. CONCLUSION: The results of this study show that QBS can predict bone loss in the FN in patients with PHPT. QBS can thus indicate the need for surgery at an early stage of the disease to prevent bone loss.     

Results of treating forearm bone shaft fractures with a 3.5 mm self compressive plate]

Elevated levels of the phaeomelanin metabolite 5-S-cysteinyldopa and the eumelanin metabolite 6-hydroxy-5-methoxyindole-2-carboxylic acid in urine and serum have been shown in previous studies to correlate with disseminated malignant melanoma. Immunohistochemical detection of S100B protein is an acknowledged method for the diagnosis of malignant melanoma, and it has been suggested that rising serum levels of S100B protein are associated with the survival rate of patients with malignant melanoma. In the present study serum levels of S100B protein and urinary concentrations of 5-S-cysteinyldopa and 6-hydroxy-5-methoxyindole-2-carboxylic acid were measured in 91 patients with histopathologically verified malignant melanoma. At the time of sampling 13 patients were in clinical stage I, 13 in stage II and 65 in stage III. The urinary levels of the melanin metabolites were determined by automated high performance liquid chromatography, and the serum levels of S100B protein by an immunoradiometric assay with two monoclonal antibodies. The overall survival rate was most strongly associated with the serum levels of S100B protein (P < 0.001), but there was also a significant correlation to urinary levels of 5-S-cysteinyldopa (P < 0.001). A corresponding association with urinary levels of 6-hydroxy-5-methoxyindole-2-carboxylic acid was found in only a very few patients with extremely high urinary concentrations. A statistically significant increase in relative hazard was found for S100B protein levels exceeding 0.6 microgram/l (P < 0.001), and predictably for patients in clinical stage III (P < 0.001). An analysis of S100B protein levels in patients in clinical stage III showed a significant correlation to survival (P = 0.005). Our study suggests that of the three biochemical tumour markers, S100B and to a lesser extent 5-S-cysteinyldopa have the greatest potential to be used as predictors of survival prognosis in patients with malignant melanoma.     

A histomorphometric evaluation of heparin-induced bone loss after discontinuation of heparin treatment in rats

Although it is well established that long-term heparin therapy causes osteoporosis, it is unknown whether heparin-induced bone loss is reversible when heparin treatment is stopped. To address this question, we randomized rats to once daily subcutaneous injections of either unfractionated heparin (1.0 U/g or 0.5 U/g) or saline for 28 days and then followed the rats for an additional 28 days off treatment. Based on histomorphometric analysis of the distal third of the right femur proximal to the epiphyseal growth plate, 1.0 U/g heparin caused a 30% loss in cancellous bone volume over the first 28 days. This was accompanied by a 137% increase in osteoclast surface and a 60% decrease in both osteoblast and osteoid surface. One month after cessation of heparin treatment, no recovery in these parameters was observed. Similarly, serum levels of alkaline phosphatase, a biochemical marker of bone formation, which continued to decrease over the course of heparin treatment, showed no signs of recovery in the subsequent 28 days off treatment. To explore the mechanism responsible for the prolonged effect of heparin on bone, we repeated the experiment giving 125I-labeled heparin in place of unlabeled heparin. 125I-labeled heparin was found to accumulate in bone during the course of its administration, and be retained in bone for at least 56 days after stopping heparin treatment. These findings suggest that heparin-induced osteoporosis is not rapidly reversible because heparin is sequestered in bone for an extended period.     

Plasma immunadsorption treatment in patients with primary focal and segmental glomerulosclerosis

BACKGROUND: In primary focal and segmental glomerulosclerosis (FSGS) renal prognosis is poor if no remission of proteinuria can be obtained by treatment. In some patients a permeability factor, responsible for damaging the glomerular epithelial cell and detectable by an in vitro test (GVV-test), seems to be present in the serum. METHOD: We determined the effects of an immunadsorption treatment (IAT) on proteinuria and glomerular permselectivity (using a neutral dextran and dextransulfate-sieving technique to assess glomerular size and charge selectivity) in five patients with FSGS in the native kidneys and three patients with recurrence of FSGS after kidney transplantation. Furthermore, we performed the GVV-test using sera obtained from the patients before and after therapy. RESULTS: IAT reduced proteinuria by more than 50% in four patients, all of whom had an improvement in glomerular-size selectivity. Charge selectivity was better preserved after therapy in three out of these four subjects. The GVV-test prior to IAT was positive in two patients who also responded clinically to therapy. After IAT the GVV-test was negative in all patients, indicating an elimination of the proteinuric factor in the two previously positive patients. CONCLUSION: We conclude that a positive GVV-test before treatment makes a favourable response of IAT on proteinuria likely in patients with FSGS. If a reduction of proteinuria can be obtained by IAT this is due to an improvement in glomerular size and/or charge selectivity.     

Immobilisation induced bone loss in the sheep is not modulated by calcitonin treatment

The effect of calcitonin on immobilisation-induced loss of cortical and trabecular bone was studied in adult female sheep. The left calcaneus of 24 adult female Welsh mountain sheep was protected from normal loading by placing an external fixator across the hock joint, from the tibia to the metatarsus. In vivo strain gauge recordings from similar animals showed that this procedure resulted in a 50% reduction in principal strain magnitude in the shaft of the calcaneus during walking. All animals received intramuscular injections three times weekly. Half of the sheep received 100 i.u. of salmon calcitonin while the remainder received vehicle alone. The experiment was conducted blind. Over the 12 week period of the experiment, dual photon absorptiometry was performed at monthly intervals to measure the bone mineral content (BMC) of the calcanei. In all the animals, the loss of bone associated with the functional protection afforded by the fixator was highly significant (p < 0.0001). There was however, no significant difference in either the amount or rate of bone loss between animals which had received calcitonin and those which had not. Post mortem measurement of the cortical thickness of the shaft of the calcaneus revealed a specific pattern of loss which was also not different in the two groups. In this model, calcitonin treatment was ineffective in preventing or retarding loss of bone associated with reduced functional load-bearing over a 12 week period.     

Surgical treatment of atrial fibrillation--experience with 9 cases

The patient was a 50-year-old alcoholic man with a left palatine tonsillar ulcer. Histopathological and bacteriological studies established the diagnosis of tonsillar tuberculosis with asymptomatic advanced pulmonary tuberculosis and multiple cerebral supra- and infratentorial tuberculomas previously unnoticed.     

Surgical treatment of children with brachial plexus paralysis

OBJECTIVE AND METHODS: A variety of surgical procedures exist for early repair of the nerve injury in obstetrical brachial plexus palsy, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can similarly be reconstructed using soft tissue and skeletal procedures. This review describes our surgical approach to maximize the ultimate functional outcome in infants and children with obstetrical brachial plexus palsy.     

Surgical treatment of syringomyelia associated with spinal dysraphism

Clinical and radiological features of syringomyelia in 15 patients with spinal dysraphism are reported. There were 8 patients with occult spinal dysraphism (lumbosacral lipoma) and 7 with spina bifida aperta (meningomyelocele). Syringomyelia with spinal dysraphism can be radiologically divided into two types according to the dysraphic state. The syrinx in the patients with occult spinal dysraphism occurred immediately rostral to the lipoma and was localized to the lower thoracic to lumbar levels, while in the meningomyelocele patients the syrinx extended from the cervical to the thoracic level. Large syrinx formation was recognized in 1 of the 7 occult spinal dysraphism cases and 3 of the 8 meningomyelocele cases. For syringomyelia with occult spinal dysraphism, 4 patients underwent syringo-subarachnoid shunting (S-S shunt, 2 cases) or syringostomy (2 cases) during an untethering operation. In the case of meningomyelocele, S-S shunts were placed in 2 patients. Collapse of the syrinx was achieved in all 6 patients who underwent S-S shunting or syringostomy. Decreased size of the syrinx was also noted in 3 occult spinal dysraphism patients who underwent untethering operations alone. In conclusion, a large syrinx in the case of spinal dysraphism should be surgically treated. S-S shunting is effective in both types of syringomyelia. Foramen magnum decompression may be an alternative method of surgical treatment for syringomyelia in patients with meningomyelocele.     

Surgical treatment of patients with open tibial fractures

Open tibial fractures are true surgical emergencies because of the risk of extensive infection to bone and devitalized soft tissue. The most serious consequence of open tibial fractures is osteomyelitis, which usually can be prevented by prompt surgical intervention within six to eight hours after injuries occur. Open tibial fractures often are the result of trauma from motor vehicle collisions, farm accidents, falls from heights, or gunshot wounds. Initial management of patients with multiple trauma injuries focuses on their life-threatening injuries before or during orthopedic surgical intervention for open tibial fractures. Orthopedic surgeons often work in collaboration with general, vascular, and plastic surgeons and perform multiple surgical procedures (eg, fasciotomy procedures for compartment syndromes, irrigation and debridement of wounds, application of external fixation devices, placement of intramedullary nails, possible limb amputations). The type and extent of open tibial fractures and soft tissue injuries determine the best treatment options for patients. Perioperative nurses should help patients focus on treatment choices for their open tibial fractures that ensure optimal surgical outcomes and maintain their quality of life.     

Analysis of bone loss with aging and menopause--using digital image processing

To study bone loss relationships to aging and menopause, cross-sectional bone mass measurements by digital image processing (DIP method), and menopause information collected by questionnaire, were analyzed on 291 women who live in Tsukude village. The results are as follows. 1) The mean DIP values (sigma GS/D, MCI) by age-stratified groups decrease with age after menopause. The rate of bone loss in sigma GS/D is almost constant, but in MCI it increases with aging. 2) In 30-year old and 40-year old age groups, the frequency distribution of DIP values is symmetrical and bell-shaped. But after the fifties the distribution is asymmetrical, with the mode of distribution deviated toward low bone mass. The change of mode with aging is larger than that of mean. This fact suggests that change of mean bone mass substantially underestimates actual bone loss from aging. 3) The change of the mean DIP values stratified by years elapsed since menopause is not especially large at start of menopause but becomes almost constant after menopause. DIP values reflect the bone loss from the aging rather than from menopause, and are beneficial to the study of bone loss in elderly women.     

Vascularized fibular grafts for the reconstruction of segmental tibial bone defects

Free vascularized fibular grafts were employed in seven patients with large tibial defects following trauma or resection of tumour. All patients were followed for more than 5 years. Tibial union and excellent functional results were achieved in all seven patients. Free vascularized fibular transfer seems to be an effective method of treatment for massive segmental bone defects.