Premature craniosynostosis a retrospective analysis of a series of 52 cases

Summary A retrospective analysis of a consecutive series of 52 cases with premature craniosynostosis is presented.Excellent functional, cosmetic, and social results could be achieved by resection of prematurely fused sutures and the creation of artificial growth sutures. Pronounced skull deformities have been corrected using the basket handle, the visor plasty, and the T-bone techniques or a combination of several of these skull form correction techniques. The surgical correction of the skull base by the frontal advancement technique in combination with orbitotomy was only necessary in 2 of our cases and could have been considered in 2 additional cases viewed retrospectively.Our results support the hypothesis that the primary cause of skull deformity is the premature closure of vault sutures and not a primary deformity of the skull base.     

Vertical lengthening of the unilateral cleft lip after a triangular flap repair

Summary A triangular flap repair for unilateral cleft lip is stated to have the potential problem of creating a lip that is too long. Although preoperative measurements were performed with calipers, the gap created in the medial segment was directly measured during the procedure, in order to determine the size of the flap more precisely. Ninety patients with complete unilateral cleft lips underwent a triangular flap repair using this method. The symmetry of the Cupid's bow was evaluated at a follow-up period averaging between six years and three months. Sixty-two lips obtained symmetry and the remaining 28 cases showed a lip which was too long; none of the lips were too short. The comparison between 27 primary palate clefts (UCLA) and 63 primary and secondary palate clefts (UCLP) showed no significant difference in the surgical result. The preoperative shortness of the lip on the cleft side was significantly greater in the too long group (5.01 ± 0.95 mm) than in the symmetry group (4.40 ± 0.87 mm). The width of the flap used was significantly larger in the too long group (3.76 ± 0.79 mm) than in the symmetry group (3.42 ± 0.69 mm). The triangular flap repair with intraoperative measurements is considered to be beneficial, although preoperative measurements provide an optimal design in most cases. It is suggested that the use of a wider triangular flap results in a lip which tends to be too long in spite of the preoperative shortness on the cleft side.     

Ureteral stents — materials and new forms

Summary Three different types of polymers are currently used for self-retained ureteral stents: thermoplastic materials such as polyurethanes, and thermoset elastomers such as silicone and hydrogels. Polyurethane stents are easy to form and have high drainage capacity, whereas silicone shows the best biocompatibility but a lower drainage efficacy than the former. A mock urinary system consisting of a collecting system and a 9-F tube was used to evaluate the flow characteristics of various double-pigtail stents in cases of urinary obstruction. For simulation of an unobstructed urinary system a human urogenital system was used. Inner flow polyurethane stents showed the best drainage as compared with inner flow silicone and outer flow ESWL stents in an obstructed ureter, whereas ESWL stents maintained the best flow in an unobstructed ureter or in respect to conventional stents with obstructed sideports.     

Urethro-vesical function during spinal shock

Summary Twenty spinal shock patients were investigated with simultaneous urethrovesical, anal and rectal pressure recordings and EMG of the external urethral and anal sphincters. Dynamic and static urethral pressure profiles (UPP) were carried out with empty and full bladder. Baldder filling was accompanied by an increased resistance in the internal sphincter zone, which in turn was paralleled in the majority of cases by an elevation of pressure in the membranous urethra without concomitant increase of its EMG activity. This is suggestive of an increased sympathetic activity in the bladder neck area and in the smooth muscle component of the external urethral sphincter. Dynamic pullthrough UPP's displayed higher resistances in the membranous urethra than static interrupted UPP's pointing to the role played by the urethral muscosal receptors in eliciting artefactual results. Higher pressures were recorded in the juxtabulbar portion of the membranous urethra than in its mid portion pointing to a gradient of pressure within the external urethral sphincter itself. The amount of EMG activity recorded in the anal and urethral sphincters at rest was somewhat decreased; high pressures and distinct reflex activity were recorded in both sphincters showing that they escape spinal shock characterized primarily by areflexia. After defining spinal shock a rational explanation based upon neuroanatomical and neurophysiological findings is offered as to why somatic activity of the sacral segments escapes it as evidenced by clincial, urodynamic, and electromyographic recordings.     

Composition and calcium binding of proteinpolysaccharides of calf nasal septum and scapula

Proteinpolysaccharide (PP-L) of resting and ossifying zones of calf scapular cartilage and of calf nasal septum cartilage was extracted with aqueous 0.15 M KCl and fractionated into a series of products: PP-L3, PP-L4, PP-L5, PP-L6. An additional proteinpolysaccharide fraction, PP-L2, was extracted from the cartilage residues with hydroxylamine. Differences in chemical composition among corresponding proteinpolysaccharides obtained from the three cartilage sources were, in general, small. The calcium binding capacity of the PP-L, PP-L2, and PP-L3 samples, as measured by equlibrium dialysis, appeared to reflect principally their uronic acid and exchangeable sulfate contents. Application of a cation exchange technique indicated that PP-L from resting and ossifying zones of scapular cartilage had similar affinities for tracer quantities of calcium. However, the affinity of PP-L from both zones of scapular cartilage for tracer quantities of calcium was greater than that of PP-L from nasal septum. The data obtained from this study do not indicate sufficient differences between the chemical composition and calcium affinity of proteinpolysaccharides from resting and ossifying scapular cartilage to account for the calcium uptake in the ossifying zone.This work was supported by the U.S. Atomic Energy Commission and by U.S. Public Health Service Special Fellowship (QTS), 1-F3-GM-16, 179–01.     

Demonstration of the 5-flap technique

Summary Demonstration of the 5-flap technique which is double opposed Z-plasty and Y – V advancement is presented. A 4×4 gauze serves to demonstrate this technique.The authors dedicate this paper to the dear memory of their teacher, the late Prof. Zvi Neuman, who passed away untimely on March 22, 1977     

Absorptiometry and “osteoporosis”: problems

connecting the dots between diverse clinical and other matters and an updated bone physiology reveals relationships that could modify some ideas about the roles and uses of absorptiometry in osteoporosis work. Herein, absorptiometry means that part of clinical densitometry that depends on X-ray absorption by bone and other tissues, thus excluding ultrasound methods and magnetic resonance imaging. The modifications concern, in part, some limitations of bone mineral density data, the kinds of physiological information that absorptiometry can and cannot provide, the relative importance of bone mass and whole-bone strength, how to define and study bone health and osteoporosis, and two kinds of osteoporotic fractures. As those modifications concern important national health care issues, they deserve answers based on hard evidence. Identifying those modifications might help others to evaluate them.     

The distribution of extracellular matrix vesicles in healing of rat tibial bone three days after intramedullary injury

Summary The distribution of extracellular matrix vesicles on the third day of bone healing was studied by morphometric analysis of transmission electron micrographs. Detection and grouping of the vesicles was performed according to type, diameter, and distance from the calcified front. The different types were selected as follows: vesicles with electron-lucent contents (empty), vesicles with amorphous electron-opaque contents (amorphic), vesicles containing crystalline depositions (crystal), and vesicles containing crystalline structures with ruptured membranes (rupture). The majority of vesicles were between 0.07 µm and 0.12 m in diameter and were located at less than 3 m from the calcified front. The distribution of the empty, amorphic, crystal, and rupture vesicles was 23.2%, 74%, 2.5%, and 0.3% respectively. Their sequence of arrangement according to diameter was as follows: empty, amorphic, crystal, and rupture, the empty vesicles constituting the smallest and the rupture the largest type. Distances from the calcified front were similar for the empty, amorphic, and crystal vesicles, while the rupture type was located nearest to the front. The present observations support the widely acknowledged hypothesis on the role of extracellular matrix vesicles in mineralization. It is thought that the secretion of empty vesicles from the cell is followed by intravscular accumulation of amorphous Ca and Pi to form a hydroxyapatite crystal that, in turn, ruptures the vesicle's membrane. The maturation process is accompanied by an increase of the vesicular diameter and its approximation to the calcifying front.     

Diagnostic approach in instability and irritative state of a “lumbar motion segment” following disc surgery—Failed back surgery syndrome

Summary A diagnostic protocol for patients with suspected instability and irritative state of a lumbar motion segment following lumbar disc surgery is presented and the results of internal fixation are analyzed.In this group of patients the clinical picture and physical signs may be quite distinct and suggestive of instability and irritation of a lumbar motion segment, however, in isolation, they do not allow to decide upon surgery. Radiological studies favour a decision for surgery only in cases with an obvious instability of a motion segment. Anaesthethizing the articular nerves permits localization of the irritable segment and non-surgical therapeutic decisions (thermocoagulation) can only be taken in cases of an isolated facet-syndrome when instability has been ruled out. The trial plaster jacket holds the most important position with respect to the indication for internal fixation as demonstrated by the conformity of the results of the plaster jacket and the results of surgery.After internal stabilization excellent, good, satisfactory and moderate results were obtained in 20, 3, 1 and 1 patients, respectively.The German term Bewegungssegment comprises all parts which are involved in the movements of one vertebral segment, i.g. disc, facet joints, ligaments and related muscles.     

34. Akute und chronische Pankreatitis. Morphologische Grundlagen

Zusammenfassung Die akute Pankreatitis zeigt mit der jauchigen Nekrose und der Vielfalt der Fettgewebsnekrosen ein eindrucksvolles Bild. Dennoch sind einige Teilaspekte wenig bekannt und für das Verständnis der Krankheit wichtig, z. B. die häufige Aussparung des Kerns der Drüse. Die anatomischen Äquivalente von Schock, Schmerz, Ileus werden erläutert, auf das Krankheitsbild Pankreatitis ohne Pankreatitis wird kurz eingegangen. Als Komplikationen werden die Chronifizierung und die Pseudocysten dargestellt. Die chronische Pankreatitis bis zur ausgebrannten Drüse mit Stein, Diabetes und möglicherweise Carcinom wird in ihrer Entstehung anatomisch gezeigt.

---

Fundamental morphological aspects of acute and chronic pancreatitis

Summary Acute pancreatitis presents an impressive picture, with autodigestic necrosis and various types of necrosis of fat tissue. Nevertheless, some side aspects are little known, although they are important to the understanding of the disease, e.g. the frequent sparing of the kernel of the gland. The anatomical equivalents of shock, pain, ileus are exvlained, and the syndrome of pancreatitis without pancreatitis will be briefly discussed. The complications of progression to a chronic state and of pseudocysts will be shown. The development of chronic pancreatitis leading to the burnt out gland with stones, diabetes and possibly carcinoma will be shown anatomically.

     

Digital subtraction angiography (DSA): New perspectives in angiography

Summary Digital subtraction angiography (DSA) has strongly influenced angiographic procedures. Because it is less invasive it has increased the total number of angiographies in all places where it was introduced. The paper gives an introduction to the procedure explaining the roles of digital and subtraction in DSA. It is written from a technical point of view. The examples are taken from and with the DVI system.     

Development of a PC-based expert system for lower urinary tract pressure-flow studies

Summary An on-line personal computer (PC)-based expert system was constructed for pressure-flow study of the lower urinary tract. An empty expert-system shell and supplementary programs were used for this system; the latter served to compensate the defects of the shell and are referred to as data programs in this report. The data programs were written in the C programming language and were used for on-line data sampling, data entry using a photoscanner, calculation of parameters, saving and loading of data, graphic display, and printing. The urodynamic pressure-flow expert system necessitates on-line data transfer, since it requires a large volume of data. However, off-line data recorded on paper was also made available for ready input by a photoscanner. Reasonable diagnostic accuracy has been achieved by our new expert system for pressure-flow studies. It should be useful in the clinical setting as well as for teaching urological students.Presented at the 19th Annual Meeting of the International Continence Society, Ljubljana, 1989, and published elsewhere as an abstract (Neurourol Urodyn 8:409–410)     

Guidelines for a short-term therapy of a torture depression

Psychotherapeutic work with torture traumas and their aftereffects are made difficult through a number of factors. Six guiding principles are presented in this publication through which make it possible to influence the actual symptomatology within the limits of the short therapy, even under difficult conditions. Creative images, described in detail as process fantasies, are the focus of this short therapy. Situative experiences in the treatment process are not interpreted with reference to the subject or the concrete trauma. This leads to the intra-psychic patterns being unlinked from traumatic torture experience patterns. With the aid of a model which discusses the torture as a superinfection with psychogenic violence-viruses, the penetration and resistance to therapy towards the torture trauma can be illuminated so that a differentiation of social and psychological factors of the torture experience is made possible.     

Spinous process-plasty following lumbar laminectomy as a contributing factor to spine stability

A 10-year retrospective study of 41 consecutive patients who underwent spinous process-plasty is presented. We carried out laminectomy of the lumbar spine in cases of spinal stenosis, dorsomedial herniated disc and recurrent disc herniation with firm scars (traumatic and tumour cases are not included). To forestall the development of laminectomy's negative effects on spine stability, we initiated the spinous processes' reconstruction. Two groups of patients who underwent laminectomy form the basis of this presentation, one group with spinous process-plasty (41 patients) and the other (11 patients) without it. On postoperative neutral and dynamic X-ray films we paid attention to horizontal displacements larger than 3 mm and to negative intervertebral angular displacement. Considering such criteria, only 3.8% of those with spinous process-plasty developed a radiographic instability in contrast to 25% of patients without spinous process-plasty. These results support the use of this technique, which provides postlaminectomy lumbar spine stability.     

Evaluation of urodynamic studies by computer

Summary In an attempt to simplify urodynamic evaluation, the data obtained from cystometry, urethral profile and flowmetry were analysed using the ICS recommendations for standardization and terminology. All studies were compiled from check lists feasible for computation. The aim was to establish standards and typical changes for the normal bladder and pathological states to enable automatic readout of computed data. The results did, in fact, show typical changes but failed to establish standard measurements suitable for completely computed diagnoses.     

Cerebral reperfusion in brain death of a newborn. Case report

A case of sudden infant death after 15 minutes of successful resusciation of cardiovascular function is presented. While apnoic cranial nerve areflexia and electrocerebral silence persisted, angiography and transcranial Doppler sonography demonstrated nearly normal cerebral perfusion, which even increased day by day inspite of the persistence of other signs of brain death. The phenomenon cerebral reperfusion is concluded to be compatible with the diagnosis of brain death.     

Triple approach for diagnosis and grading of meningiomas: Histology,morphometry of Ki-67/feulgen stainings,and cytogenetics

Summary With regard to meningioma grading and the recently introduced atypical meningioma, we evaluated 160 cases retrospectively by conventional histology and image analysis. For that, the cell nuclei were stained with a Ki-67 (MIB1)/Feulgen-method on paraffin sections, thus enabling the assessment of both the Ki-67 proliferation index and nuclear morphometric features, such as tumour cell arrangement, nuclear pleomorphism, and cellularity.It could be demonstrated that the Ki-67 proliferation index is the most important criterion for distinguishing anaplastic meningiomas (WHO grade III) (mean Ki-67 index: 11%) from those of common type (WHO grade I) (mean Ki-67 index: 0.7%). The parameter for the relative volume weighted mean nuclear volume is another valuable morphometric feature. The atypical meningioma (WHO grade II) which should represent an intermediate category between common type and anaplastic meningiomas is characterized by a mean Ki-67 proliferation index of 2.1%. Common type meningiomas which comprise almost 50% of the cases of this series have a relapse rate of 9%. Atypical and anaplastic meningiomas recurred in 29% and 50%, respectively. Since the term atypical meningioma is confusing in the context of tumour grading, the term intermediate type meningioma is proposed.Furthermore, the results of cytogenetic analyses of 142 cases of this series were evaluated and compared with the meningioma grades. Thereby, 25 cases disclosed, independent of the typical loss of one chromosome 22, cytogenetic features assumed to be progression-associated, e.g., the gain or loss of different chromosomes and the deletion of the short arm of one chromosome 1 (hyperdiploidy, increased hypodiploidy, Ip-), when correlated to the histological and morphometric findings or the high relapse rate.For meningioma diagnosis and grading, a practical guideline is proposed based upon histology, morphometry (Ki-67), and cytogenetics.     

Effect of ipriflavone in combination with calcium supplements on bone metabolism in elderly osteoporotic women

Ipriflavone and calcium supplements are used in the treatment of osteoporosis. However, the effect of ipriflavone in combination with high-dose calcium supplements (1 g/day) on bone metabolism in elderly osteoporotic women is still a matter of controversy. Enrolled in this study were 22 women over 70 years of age diagnosed as having involutional osteoporosis. The patients were randomly assigned to treatment with either ipriflavone plus calcium or with calcium supplements only for 6 months. Biochemical markers of bone metabolism and bone mass of the hand were determined at baseline and at 6 months. Serum parathyroid hormone, serum osteocalcin, serum alkaline phosphatase, and the urinary hydroxyproline/creatinine ratio decreased in both groups. These decreases were greater in the ipriflavone plus calcium supplement group than in the calcium supplement only group. Serum calcitonin increased in the ipriflavone plus calcium supplement group. Metacarpal index and metacarpal bone mineral density did not change in either group. These findings suggest that treatment with ipriflavone plus calcium supplements may inhibit bone resorption and modulate bone turnover in elderly osteoporotic women and may be more effective than calcium supplements alone.     

Nasal anatomy: The muscles and tip sensation

The author stresses the importance of columellar sensation, nasal tip sensation, and the role of the nasalis muscles in determining the postoperative results of corrective rhinoplasty, especially as these have an influence on the drooping tip and the columellar base. Specific anatomic details of this area are emphasized in order to help the plastic surgeon understand better the normal anatomy of this region and the effects that operative procedures have on successful results if the surgeon understands especially the role of the nasalis muscles.     

Replacement of the anterior cruciate ligament

Summary Eighty-seven patients have been examined 2 years on average after knee ligament reconstruction for a torn anterior cruciate ligament. The patients were divided into four groups according to the type of operation that had been carried out. In the first group an extra-articular lateral repair (MacIntosh tenodesis) had been performed, in the second group an intra-articular over-the-top repair using the quadriceps and the patellar tendon, in the third group a modified Eriksson procedure using the patellar tendon, and in the fourth group a combined intra- and extra-articular repair using carbon fibres as a graft. The results of the operations in the different groups are compared. The best results were obtained with the Eriksson procedure, closely followed by the over-the-top repair. Limited range of motion and retropatellar pain resulting from changes in the alignment of the patella were the main problems. The results after the use of carbon fibres were less good. In two cases the graft tore without further trauma, and there were also problems because of restricted range of motion and retropatellar pain. The worst results were found after extra-articular lateral repair, due to insufficient stability in many cases. However, the best results with regard to the range of motion were found in this group.

---

Zusammenfassung Es wurden 87 Patienten im Durchschnitt 2 Jahre nach Ersatzplastik bei zerrissenem vorderem Kreuzband und chronischer Instabilität nachkontrolliert. Die Patienten wurden in vier Gruppen eingeteilt. In jeder Gruppe war eine andere Art von Ersatzplastik durchgeführt worden. In der ersten Gruppe war es ein extraartikulärer lateral repair (sog. MacIntosh-Plastik), in der zweiten Gruppe eine intraartikuläre over the top geführte Plastik mit der Quadriceps- und der Patellarsehne, in der dritten eine modifizierte Eriksson-Plastik unter Verwendung der Patellarsehne und in der vierten Gruppe eine kombinierte intra- und extraartikuläre Plastik mit Carbon fibres. Die Resultate der Operationen in allen vier Gruppen werden miteinander verglichen. Die besten Ergebnisse zeigte das Vorgehen nach Eriksson, dicht gefolgt vom over the top-repair. Probleme, die in diesen zwei Gruppen auftraten, betrafen eingeschränkte Kniebeweglichkeit und retropatelläre Schmerzen wegen veränderter Führung der Patella. Die Resultate in der Gruppe mit Verwendung der carbon fibres waren weniger gut. In zwei Fällen ist das Transplantat ohne Trauma gerissen, zudem traten auch hier Beschwerden auf wegen eingeschränkter Beweglichkeit und retropatellärer Schmerzen. Am wenigsten gut waren die Resultate nach extraartikulärem lateral repair. In vielen Fällen konnte durch these Methode keine genügende Stabilität erreicht werden. Andererseits war die Beweglichkeit des Kniegelenkes nach dieser Operation kaum je eingeschränkt.