Use of the suture anchor in open Bankart reconstruction. A follow-up report

We previously reported early results of a new technique using a suture anchor to perform a modified Bankart reconstruction. That study included patients from two medical centers and had an average followup of only 1 year. This report includes patients from a single center with followup extended to a mean of 42 months (range, 33 to 61). Between April 1988 and August 1991, 53 patients with recurrent anterior glenohumeral instability underwent modified Bankart reconstruction with the use of a suture anchor. Thirty-two patients met inclusion criteria (identifiable Bankart lesion, open repair with suture anchors, and minimum followup of 2 years); 4 patients were lost to followup. There have been no complications as a result of this technique. Ninety-three percent of the patients in the study had objectively excellent or good results. There were 2 failures with recurrent anterior dislocation. The use of a suture anchor can simplify the Bankart reconstruction. At average followup of 3 years, 26 patients have returned to presurgery activity levels without recurrent dislocation or subluxation. However, careful attention to anchor placement at the junction of articular cartilage and the glenoid neck is necessary to avoid technical failure.     

Biomechanical study of sternal closure using rigid fixation techniques in human cadavers

BACKGROUND: We believe rigid plate fixation may be superior to wire fixation in sternal closure, as rigid fixation used in the craniofacial skeleton has shown greater stability, lower postoperative pain, and accelerated bone healing. We hypothesize that sterna fixed with titanium plates are more stable mechanically than sterna fixed with wires. METHODS: The sterna from human cadavers were used in this two-phased study. Phase I compared wires to four-hole titanium straight plates. Phase II compared wires to four-hole titanium custom H plates. The sterna were tested biomechanically using all fixation methods. RESULTS: Phase I showed no statistically significant difference in the stiffness or lateral displacement between the wired and straight plated sterna. Phase II showed a statistically significant greater stiffness (p < 0.05) and less lateral displacement (p < 0.05) in the custom plated sterna over the wired sterna. CONCLUSIONS: Our results showed that custom titanium H plates were superior to wire fixation. Furthermore, our results established the importance of plate configuration in sternal fixation. Our study may have beneficial clinical implications, as decreased motion at the sternotomy site could mean less postoperative pain, a decreased incidence of infection, and accelerated bone healing.     

The use of the Synthes 7.3-mm. cannulated screw in rearfoot and ankle surgery: a preliminary prospective study

The authors present a preliminary prospective study of the Synthes 7.3 mm. cannulated screw used in 31 rearfoot and ankle surgeries on 29 patients. The patients had a variety of rearfoot and ankle procedures performed, in which a total of 75 screws were placed across 47 arthrodesis or osteotomy sites. The percentage of union or healing was 95.74% for the joints or sites involved. The average healing time was 2.71 months. The techniques for placement of the screw are described.     

Results of three different stapedectomy techniques: a comparative study]

We perform a comparative study on the results obtained through three stapedectomy techniques. The hearing gain was evaluated in 107 ears with total footplate removal, Shea prosthesis and connective tissue graft, in 81 ears with particular footplate removal, the same prosthesis, and no tissue graft, and in 66 ears with stapedectomy. The differences between the three groups in the air-bone gap closure or postoperative complications were not statistically significant. We conclude that results depend more on the surgeon than on the technique.     

Prediction of fatigue screw loosening in anterior spinal fixation using dual energy x-ray absorptiometry

STUDY DESIGN: A biomechanical study was performed to investigate a relation between the bone mineral density of the vertebral body and the number of loading cycles to induce fatigue loosening of an anterior vertebral screw. OBJECTIVES: The objective of this study was to investigate the potential usefulness of dual energy x-ray absorptiometry of measuring bone mineral density of the vertebral body in predicting the fatigue loosening of th anterior vertebral screw. SUMMARY OF BACKGROUND DATA: Loosening of the vertebral body screw is a well know failure in spinal instrumentation, and more commonly observed than pullout failure. The relation between bone mineral density and pullout strength of the screw has been investigated previously, but no studies are available on the fatigue loosening in anterior spinal fixation. METHODS: Bone mineral density was measured using dual energy x-ray absorptiometry and the screw loosening was produce by a cyclic loading in the cephalad-caudal direction. Screw loosening was defined as 1 mm displacement of the screw relative to bone, and the number of loading cycles to induce the screw loosening was obtained and statistically correlated with bone mineral density. RESULTS: There was a positive correlation between the number of loading cycles to induce screw loosening and bone mineral density (R = 0.8, P < 0.01). The average number of loading cycles to induce screw loosening was significantly less for specimens with bone mineral density < 0.45 g/cm2 compared to those with bone mineral density > or = g/cm2. CONCLUSIONS: These findings suggest that bone mineral density may be a good predictor of anterior vertebral screw loosening. Bone mineral density < 0.45 g/cm2 may be critical value of loosening of the anterior vertebral body screw. However, further biomechanical and clinical studies are required before using threshold value clinically.     

Pedicle screw fixation for arthrodesis of the lumbosacral spine in the elderly. An outcome study

STUDY DESIGN: An analysis of the outcome and effectiveness of instrumented arthrodesis of the lumbosacral spine in elderly patients conducted using a review of records, assessment of fusion via plain radiographs, and a two-part questionnaire. OBJECTIVE: To ascertain the outcome and efficacy of instrumented arthrodesis of the lumbosacral spine in patients 60 years of age and older. BACKGROUND DATA: From 1987 to 1991, 38 patients of at least 60 years of age underwent instrumented arthrodesis of the lumbosacral spine using the Wiltse or Selby pedicle screw fixation system (Advanced Spine Fixation Systems, Inc., Irvine, CA). Patients were considered for surgery only after attempts at conservative management, including physical therapy, medication, injection blocks, and home exercises, had proven unsuccessful. METHODS: Follow-up examinations were performed 3 months, 6 months, 1 year, and 2 years after surgery. Fusion was assessed using plain radiographs, including flexion-extension films. Inpatient and outpatient records were reviewed, and a two-part questionnaire was used to establish the effect of surgery on function and lifestyle. Thirty patients responded to the questionnaire. Follow-up observation of the patients ranged from 25 to 56 months. The mean age was 73.8 years (range, 60-90 years). RESULTS: The mean co-morbidity was 1.7. Based on the authors' method of evaluation of fusion, the fusion rate was 92%. Fifty-seven percent of the patients reported excellent or good results, 26% reported fair results, and 17% reported poor results. Functional gains of 50% or more were reported by 71% of the respondents. Female patients had significantly more complications than male patients, but reported comparable outcomes. CONCLUSION: Despite the increase in age, co-morbidity, and associated risk of perioperative complications inherent in this population, an outcome comparable with that of younger patients is reported.     

Clinical evaluation of the centrifugal pump in open heart surgery: a comparative study of different pumps

Pulmonary embolism after cardiac surgery is attributed to embolization from thrombus within the deep venous system. We report two cases of pulmonary embolism after coronary artery bypass surgery in which transesophageal echocardiography detected in situ right atrial thrombus. The right atrium should be screened for thrombus in patients who have pulmonary embolism after cardiac surgery.     

Safe lateral-mass screw lengths in the Roy-Camille and Magerl techniques. An anatomic study

STUDY DESIGN: Investigation of the mean safe lateral-mass screw lengths in the Roy-Camille and Magerl screw techniques in cadaveric cervical specimens. OBJECTIVES: To report the mean screw path length and to evaluate the relation of the screw trajectory to the nerve root in the Roy-Camille and Magerl screw techniques. SUMMARY OF BACKGROUND DATA: Potential injury to the cervical nerve root caused by too long a screw remains a major concern. Few studies regarding proper screw length and its relation to the adjacent nerve root are available. METHODS: Fourteen cervical spines were used for this study. Each lateral mass from C3 to C7 was drilled according to the techniques described by Roy-Camille (right side) and Magerl (left side). The cervical spines were harvested from the cadavers, and the anterior aspect of the lateral mass and spinal nerve were exposed. The screw path length between the dorsal and ventral cortices of the lateral mass were measured. An additional measurement was taken from the ventral aspect of the lateral mass to the nerve root along the screw path. RESULTS: The mean screw path length in the Roy-Camille technique decreased consistently from C3 (15.7 +/- 1.7 mm) to C7 (11.3 +/- 0.8 mm). The mean distance from the ventral cortex to the nerve root ranged from 1.2 to 2.3 mm, and the smallest value was at C7. The mean screw path length in the Magerl technique also decreased from cephelad to caudal, with a range of 15-16 mm at C3-C6 and a mean value of 13.8 mm at C7. CONCLUSIONS: A safe screw length is 14-15 mm in the Roy-Camille technique and 15-16 mm in the Magerl technique at C3-C6. A short screw may be used at C7 if desired.     

Safety and accuracy of transarticular screw fixation C1-C2 using an aiming device. An anatomic study

STUDY DESIGN: In this anatomic study, the safety and accuracy of C1-C2 transarticular screw placement was tested in a normal anatomic situation in cadaver specimens using a specially designed aiming device. OBJECTIVES: To assess the safety and accuracy of transarticular screw placement using the technique described by Magerl and a specially designed aiming device. SUMMARY OF BACKGROUND DATA: Transarticular C1-C2 screw fixation has been shown to be biomechanically superior to posterior C1-C2 wiring techniques. Several clinical series have been reported in the literature. However, no previous study assessing the accuracy or safety of this technique has been published. Structures at risk are the vertebral arteries, spinal canal, and the occiput-C1 joint. METHODS: Five frozen human cadaveric specimens were thawed and instrumented with 10 C1-C2 transarticular screws, according to the technique described by Magerl but using a specially designed aiming device described by the senior author (Jeanneret). After screw placement, the accuracy of screw positioning and the distance of the screws from the spinal canal, vertebral arteries, and atlanto-occipital joint were determined by anatomic dissection and radiographic analysis. RESULTS: The structure at greatest risk was the atlanto-occipital joint, with one screw found to be damaging the joint. Vertebral artery or spinal canal penetration was not observed in any of the specimens. Screw length averaged 45 mm and, with proper length, the screw tip was found to be located approximately 7.5 mm behind the anterior tubercle of C1 on lateral radiographs. CONCLUSIONS: This anatomic study demonstrates that C1-C2 transarticular screw fixation can be performed safely in a normal anatomic situation by surgeons who are familiar with the pertinent anatomy. The aiming device allowed safe instrumentation in all patients. In case of an irregular anatomic situation (e.g., congenital abnormalities or trauma), computed tomographic scan with sagittal reconstruction is recommended-in particular, to obtain information about the course of the vertebral artery.     

Nikolai Terebinski: a pioneer of the open valve operation

On the occasion of the hundredth anniversary of heart surgery, this article presents the remarkable work of the Russian scientist and surgeon Nikolai Terebinski. The medical world today remains largely unaware that he performed the first successful open valve operations. These experimental operations were conducted in Russia between 1926 and 1937 through the use of an extracorporeal circulation device known as the autojector. The experiments were reviewed based on Terebinski's original articles and experimental notes. Here we present the techniques and results of his landmark open valve operations on dogs. He performed more than 250 open valve operations, which were the first of their kind. In his attempt to create and then later correct tricuspid and mitral valve stenosis and insufficiency, Terebinski developed many principles of open heart surgery that are valid today. His work represents a milestone in the history of heart surgery.     

Adoptive immunotherapy of murine lymphosarcoma: comparative study using allo-immune or tumor-immune T cells

The antitumor effect of allosensitization with lymphocytes and skin graft of DBA/2 mice was evaluated using immunogeneic, transplantable Lymphosarcoma (LS-A) syngeneic to Swiss mice. A dose dependent tumor inhibitory effect in terms of tumor free mice was observed in mice sensitized i.p. with lymphocyte doses between 10-100 million per animal. Sensitization with allogeneic primary skin graft was more effective than lymphocyte immunization. The antitumor immunity could be adoptively transferred in syngeneic Swiss mice using either allo-immune or tumor-immune T cells. Analysis of T cell phenotypes using monoclonal antibodies against cell surface markers CD4 and CD8, indicated absolute dependence on the CD4+ T cells subset in tumor cure in case of allo-immune as well as tumor-immune T cells. CD8+ T cell subset was found essential only in case of allo-immune T cell therapy. Immunosuppression of mice with whole body gamma irradiation (4 Gy), 6 hr before transfer of allo-immune or tumor-immune T cells did not abrogate the therapeutic ability of allo-immune or tumor-immune T cells. Our results suggest that allosensitization could be an effective method of generating effector lymphocyte populations that might be used to treat tumors that exhibit detectable immunogenecity.     

A comparative study of sibship tests of linkage and/or association

Population-based tests of association have used data from either case-control studies or studies based on trios (affected child and parents). Case-control studies are more prone to false-positive results caused by inappropriate controls, which can occur if, for example, there is population admixture or stratification. An advantage of family-based tests is that cases and controls are well matched, but parental data may not always be available, especially for late-onset diseases. Three recent family-based tests of association and linkage utilize unaffected siblings as surrogates for untyped parents. In this paper, we propose an extension of one of these tests. We describe and compare the four tests in the context of a complex disease for both biallelic and multiallelic markers, as well as for sibships of different sizes. We also examine the consequences of having some parental data in the sample.     

Translaminar screw fixation of the lumbar and lumbosacral spine. A 5-year follow-up

STUDY DESIGN: In a retrospective study, the long-term results of translaminar facet screw fixation of the lumbar and lumbosacral spine are reviewed. OBJECTIVES: To evaluate the clinical results, fusion rates and complications of this posterior fusion technique in various conditions of the lumbar spine. SUMMARY OF BACKGROUND DATA: Posterior fusion of the lumbar and lumbosacral spine is one of the possible methods to relieve pain and eliminate instability in degenerative conditions. Data in the literature support the use of internal fixation to optimize the rate of fusion. METHODS: Posterior lumbar and lumbosacral fixation with translaminar screws and fusion in 173 patients with degenerative changes with or without compressive syndromes including failed back syndromes, monosegmental hypermobilities, and posttraumatic conditions were investigated. Fixation and fusion with translaminar screws was performed in 57% monosegmentally, in 40% across two segments and in 2% over three segments. Decompressive surgery was performed in addition in 52% and nucleotomy in 30% of the cases. Clinical and radiologic assessment with flexion/extension x-rays was performed in 145 (83%) patients by two independent orthopedic surgeons. After an average follow-up of 68 months (range, 52-83). RESULTS: Ninety-four percent of the patients showed solid bony fusion in the radiologic follow-up. Loosening of the screws was noted in 3%, and two screws were broken without apparent motion on the functional x-rays. Pain scores decreased from 7.6 before surgery to 2.9 after surgery on a 10-point pain scale. The results were further analyzed according to Stauffer and Coventry with 99 good results, 70 satisfactory results, and 4 bad results. CONCLUSIONS: Translaminar screw fixation offers an immediate postoperative stability of the lumbar and lumbosacral spine and enhances fusion. In the present series no neurologic complications were noted. It represents a useful and inexpensive technique for short segment fusion of the nontraumatic lumbar and lumbosacral spine.     

Differential activation of phospholipases during necrosis or apoptosis: a comparative study using tumor necrosis factor and anti-Fas antibodies

Successful efforts to improve levels of physical activity in the population are contingent upon an accurate understanding of the determinants of habitual activity. While most research has focused on psychosocial and environmental influences, the potential effect of intrinsic biological control on regular activity has received little attention. This review examines evidence for the existence of such central control, offers a rationale for its function, and suggests implications for preventive health strategies resulting from a biological contribution to habitual activity levels.     

Less blood damage in the impeller centrifugal pump: a comparative study with the roller pump in open heart surgery

A centrifugal pump with an impeller (Nikkiso Centrifugal Pump, Model HPM15; Nikkiso Co. Ltd.) was applied to cardiopulmonary bypass (CPB) in 14 patients who underwent elective coronary artery bypass grafting. Serum hemoglobin level, platelet count, and serum beta-thromboglobulin (beta TG) level were measured during CPB. The results were compared with those obtained in a comparative roller pump (RP) group (n = 10). There was no difference in the time on CPB between the NP (109 min) and RP (121 min) groups. The serum beta TG level (ng/ml) was lower in the NP group than in the RP group (obtained 90 min after the initiation of CPB). The plasma-free hemoglobin level also was lower in the NP group than in the RP group (obtained 90 min after the initiation of CPB, 120 min after the initiation of CPB, immediately after the termination of CPB, 3 h after termination of CPB; p < 0.01). There was no significant difference in platelet depletion. The HPM15 pump showed excellent hemodynamic performance with less blood trauma compared with the roller pump in its clinical application to open heart surgery.     

Carbonated apatite cement augmentation of pedicle screw fixation in the lumbar spine

STUDY DESIGN: Biomechanical testing with human cadaveric lumbar vertebral bodies was used to determine the utility of an injectable carbonated apatite cancellous bone cement for improving the structural performance of pedicle screws subjected to axial pull-out or transverse cyclic loading. OBJECTIVES: To ascertain whether augmentation with a carbonated apatite cement can enhance pedicle screw fixation in the lumbar spine. SUMMARY OF BACKGROUND DATA: The beneficial effects of polymethylmethacrylate augmentation on pedicle screw pull-out strength have been demonstrated. Cancellous bone cement, however, may provide an attractive alternative in this application, as it is remodelable, biocompatible, and nonexothermic. METHODS: Forty-three cadaveric lumbar vertebral bodies were instrumented with pedicle screws. In 20 of these specimens, axial pull-out strength was compared between the control screws and those augmented with cancellous bone cement. In the remaining 23 specimens, the screws were loaded in the superior-inferior direction with a peak displacement of +/- 1 mm at a frequency of 3 Hz for 5000 cycles. Three parameters were calculated from the force-versus-time data: 1) the energy dissipated, 2) the peak force at the start of the test, and 3) the peak force at the end of 5000 cycles. RESULTS: The pull-out strength of the augmented pedicles averaged 68% greater than that of the control side. In response to cyclic loading, all measures of bio-mechanical performance improved 30-63%. CONCLUSIONS: The data suggest that augmentation with this carbonated apatite cancellous bone cement can enhance immediate screw fixation.     

A comparative clinical study on flucytosine alone and in combination with fluconazole in hematological malignancies: a multicenter study using the envelope method

Two different flucytosine (5-FC) treatment regimens, one by itself and the other in combination with fluconazole (FLCZ) were compared in chemotherapy against mycotic infections in 60 patients with hematological diseases. The patients in a randomized fashion were assigned to the two treatments. In the combination regimen, the two drugs were used in half doses. beta-D-Glucan and D-arabinitol in the sera of patients were measured to document mycotic infections, and bacterial examinations were also performed. The efficacy of the combination therapy was 60.0% (18/30) and that of 5-FC alone was 65.5% (19/29). The stratified evaluation indicated that no factor was found to contribute to the efficacy in the two treatments with statistical significance. The side effects occurred in few cases and none of those was serious; including, one case of subjective symptom in each groups and two episodes of liver dysfunction in combination treatment. Changes in beta-D-glucan concentrations in the sera reflected well the pathophysiology of mycotic infections and clinical improvement. These results suggested that a combination of 5-FC and FLCZ at half doses provided a clinical benefit comparable to 5-FC alone at the ordinary dose, and the safety was considered satisfactory.