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.     

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.     

The Graf stabilisation system: early results in 50 patients

Summary The results of the first 50 consecutive patients using the Graf stabilisation system are presented. The average age of the patients was 41 years; there were 32 women and 18 men in the group. All patients suffered from intractable symptomatic degenerative disc disease which could be localised to one or more levels. All patients gave a history of chronic back pain, but the mean period of severe disability was 24 months. The mean preoperative disability score (Oswestry questionnaire) was 59%. The average period of follow-up was 24 months (range 19–36 months). At the latest review, the mean disability ability score was 31%. The clinical results were classified as excellent or good in 72% of patients, fair in 10%, the same in 16% and worse in 2%. All but three patients felt that surgery was worthwhile. The results have not deteriorated over the period of follow-up.     

Polymeric pyelotomy

A non-toxic, soluble polymeric preparation MAG with controlled period of gelation was synthetized for the extraction of stones from the pyelocalyceal system during surgery for urolithiasis.With respect to toughness the preparation proved superior to the fibrinogenthrombin mixture, used in the so-called fibrin pyelotomy according to Dees. Its biologic testing in animals (rabbits, dogs and pigs) yielded excellent results.By analogy with fibrin pyelotomy we took the liberty to propose the term polymeric pyelotomy.     

Urolithiasis,inhibitors and promoters

Summary The aim of this work is to evaluate the role and importance of inhibitors and promoters in urolithiasis. Carrying in mind theoretical considerations, we conclude that in urolithogenic processes, inhibitors and promoters could only play a decisive role in the idiopathic oxalocalcic urolithiasis. We classify the idiopathic oxalocalcic stone-formers into three main groups, considering inhibitory and promoting factors. It is shown that such classification is in good agreement with the clinical results observed in a group of 88 idiopathic oxalocalcic stone-formers.     

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     

An interpretation of acute changes in plasma45Ca following parathyroid hormone administration to thyroparathyroidectomized rats

Acute changes in plasma calcium and⁴⁵Ca were studied in young adult male thyroparathyroidectomized (TPTX) rats injected with moderate doses of parathyroid hormone (PTH). For plasma calcium changes, comparison was made between rats fasted or fed prior to PTH injection. For plasma⁴⁵Ca changes, the effect of the time of administration of the radionuclide was also studied; this included rats injected with PTH 1 h after radionuclide (1 h⁴⁵Ca), 18 h later (18 h⁴⁵Ca) and more than 6 days later (6 day⁴⁵Ca). The results can be summarized as follows: (1) Plasma calcium changes were greater when PTH was injected into fed rather than into fasted rats. (2) PTH always produced a relative increase (compared to controls tested concurrently) in plasma⁴⁵Ca concentrations. This increase was the same in the 1 h⁴⁵Ca and the 18 h⁴⁵Ca groups. (3) Plasma⁴⁵Ca rose at least temporarily following PTH injection in the 18 h⁴⁵Ca group. (4) The⁴⁵Ca rise following PTH was always greater in fed than in fasted groups. (5) Plasma⁴⁵Ca specific activities (S.A.) tended to rise in the 6 day⁴⁵Ca group and to fall in the 18 h⁴⁵Ca group, following PTH injection. However, the⁴⁵Ca S.A. was always higher in fed than fasted groups. (6) In a few experiments in which³²P was injected with⁴⁵Ca, specific activity changes in plasma⁴⁵Ca following PTH injection werenot accompanied by similar changes in³²P specific activity.These results could not be adequately explained by PTH effects on bone resorption, but the data supported the postulate that PTH controls plasma calcium concentrations by increasing transport of calcium through the osteocyte-lining cell (osteoblast) bone cell complex from the bone fluid compartment to the ECF.     

Multifactorial genesis of neuroradiological “leucoencehalopathies”

Three cases of neuroradiologically diagnosed leucoencephalopathy are reported. Histopathological examination disclosed Binswanger's encephalopathy in Case 1, congophilic angiopathy with secondary leucoencephalopathy in Case 2, and HIV encephalopathy with secondary white matter changes in Case 3. These three cases demonstrate the unspecificity of neuroradiological findings in leucoencephalopathy.     

Subluxation of the patella

Summary Subluxation of the patella may produce pain and instability in young people. However its classification, diagnosis and treatment are controversial. We have used computerized tomography (CT) to measure the amount of lateral shift of the patella and the angle of tilt to the femur in patients with subluxation. The mean lateral shift was 31.4% and the angle of tilt 31.8 degrees. These values are significantly greater than those obtained from conventional axial radiographs or in arthrographic axial views.We have obtained interesting evidence that the rate of lateral shift apparently increased on voluntary contraction of the quadriceps muscle (Q-contracted). With the quadriceps contracted, the mean rate of the lateral shift in the affected knees showed a significant increase (+ 27.7%) compared to that in normal knees (+ 14.0%).We have reviewed 40 knees treated by operative realignment with a mean follow-up of 27 months. The mean rates of lateral shift measured from CT-image in the knees before operation improved significantly to the normal range at follow-up, both with the quadriceps relaxed and contracted. The results evaluated by Insall's criteria were excellent in 13 knees; good in 22; fair in 3 and poor in 2. The satisfactory group (those with excellent and good results) revealed an improvement in lateral shift when the quadriceps was contracted, while the unsatisfactory group (fair and poor results) did not.Read at the 16th Congress of the Société Internationale de Chirurgie Orthopédique et de Traumatologie, City of London, England     

Reconstruction of the temporal hairline

Reconstruction of the temporal hairline is usually discouraged because of unsuccessful results. A technique using punch hair grafts and micrografts is presented that has shown good cosmetic results.     

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.     

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.     

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.     

Preventive treatment of nephrolithiasis with alkali citrate—a critical review

Using the keywords urolithiasis and citrate treatment, nephrolithaisis and citrate treatment, kidney stones and citrate treatment, a Medline search revealed 635 articles published between 1 January 1966 and 1 December 2004. For the present analysis, only studies meeting all of the following criteria were included: (1) publications in English or German, (2) studies on preventive alkali citrate treatment in patients with calcium oxalate, uric acid and infection stone disease, (3) clinical studies including at least ten subjects, and (4) treatment phases of at least 1 week duration. A total of 43 studies met the inclusion criteria and were further subclassified according to intermediate or ultimate endpoints as well as to study design. With stone recurrence as the ultimate endpoint, 21 uncontrolled studies in almost 1,000 patients demonstrated a reduction in stone forming rate by 47–100%. In four randomized controlled trials including 227 patients, 53.5% on alkali citrate vs 35% on placebo remained stone-free after at least 1 year of treatment (P<0.0005). Similar values (66% vs 27.5% for alkali citrate vs placebo, P<0.0005) were obtained in 104 patients from two randomized trials with dissolution/clearance of residual stones as endpoint. Unfortunately, up to 48% of alkali citrate treated patients left the studies prematurely, primarily due to adverse effects such as eructation, bloating, gaseousness or frank diarrhea.     

Selective transposition of the pectoralis major myocutaneous flap: an electromyographic evaluation

Although it has been postulated that the segmental anatomy of the pectoralis major muscle should allow intact motor function to be preserved at the donor site after a myocutaneous island flap has been transposed, the functional outcome of this selective harvesting technique has not been previously investigated. In this study the degree of innervation of the residual pectoralis major muscle on the chest after traditional (10 patients) and selective (10 patients) pectoralis major myocutaneous flap transposition has been evaluated using postoperative electromyography. According to the data obtained, while an intact innervation of the external segment is maintained utilizing both techniques, it is impossible to preserve functional innervation of the remaining sternocostal strip medial to the donor site during a pectoralis major myocutaneous flap transposition, even after its selective harvesting.     

Quantitative evaluation of the bacteriostatic efficacy of amniotic membrane applied as a biological dressing over large contaminated wounds encountered in clinical practice

Summary Control of wound infection constitutes the most important aspect of wound management. A successful wound closure either by delayed primary/secondary suturing or by skin grafting cannot be performed unless the bacterial count in the tissues is well below the critical number of 10⁵ organisms per gram of tissue. In this study, the efficacy of the amniotic membrane in reducing bacterial infection when applied as a biological dressing over granulating wounds was compared with that of standard saline dressings. Bacteriological monitoring of wound flora was achieved by a three dimensional biopsy from an active portion of the infected wound. Such biopsies were taken from both test and control areas before membrane application and 72 h after application. The results of this study demonstrate that amnion dressings have a definite and significant antibacterial effect as seen by the marked decrease in bacterial colony counts after the dressing is applied to contaminated wounds. This effect of the amnion can be attributed to the intimate biological closure due to its excellent adherence on to the wound bed, facilitation of phagocytosis of the micro-organisms in the underlying healthier granulations and to certain antibacterial substances elaborated by the living amniotic cells.Presented at the Peet Prize Scientific Session of the 24th National Conference of the Association of Plastic Surgeons of India at Baroda, September 2, 1989     

In-vivo and ex-vivo renal preservation

Summary A new renal perfusate of modified intracellular electrolyte composition made hyperosmolar with mannitol and requiring no additional additives was successfully used to preserve canine kidneys ex-vivo for 48 hours by initial perfusion and hypothermic storage. The new perfusate was also successful in protecting totally ischemic canine kidneys from the lethal effect of two-hours of normothermic exposure in-vivo. — The preservation technique is uncomplicated, the materials involved are inexpensive, and the preservation apparatus is readily transportable.Supported by the Max Kade Foundation, New York, New York.     

Intracranial meningiomas: Analysis of recurrence after surgical treatment

Summary Recurrence of intracranial meningiomas after surgery has long been recognized, but there is still no consensus about factors responsible for recurrence. To better understand such factors, we analysed data on 276 patients with meningiomas who were treated at our institution from 1976 to 1990 (mean follow-up=5.1 years). Effects of sex, tumour histology, tumour site, and radiotherapy on recurrence were closely studied. Using World Health Organization criteria to define malignancy, 254 of the tumours were benign and 22 were atypical or malignant. For data analysis, distinction was made between recurrence (i.e., reappearance of tumour after total resection) and regrowth (i.e., tumour enlargement after subtotal removal). Recurrence was seen in 2 of 183 benign meningiomas and in 10 of 16 malignant meningiomas. Recurrence and regrowth rates for malignant meningiomas far exceeded those for benign meningiomas (p=0.001). Neither sex nor tumour site was associated with subsequent recurrences in patients whose tumours had been completely resected.The influence of radiotherapy was studied in terms of its effects on benign versus malignant meningiomas, whether given after complete or incomplete resection, and whether given after primary resection or on reoperation. We found that radiotherapy did not decrease recurrence or regrowth regardless of when administered, either at first resection or on recurrence. This was true for benign as well as malignant meningiomas. However, due to the small number in our series, we cannot conclude that radiotherapy has no beneficial role in the treatment of meningiomas.We do believe that the rate of recurrence for benign meningiomas is far lower than has been reported and that the majority of recurrences are in fact regrowths representing continuous tumour growth after incomplete removal. In fact, whenever recurrence is seen after complete surgical removal, chances are that tumour was atypical or malignant.     

33. Der „kalte” Schilddrüsenknoten

Zusammenfassung Der kalte Schilddrüsenknoten gilt als typischer Verdachtsbefund für ein Schilddrüsencarcinom. Seine tatsächliche Dignität ist mit klinischen Mitteln sowie Szintigraphie und Sonographie letztlich nicht zu klären. Das beste abgrenzende Selektionskriterium ist die Feinnadel-Punktionscytologie, wodurch mit Gültigkeit für das Kropfendemiegebiet etwa die Hälfte als suspekte Befunde von dem anderen Teil hochwahrscheinlich gutartiger Veränderungen getrennt und für die Operationsindikation reserviert werden kann.     

Re-integration stress for Desert Storm families: Wartime deployments and family trauma

Because the war was relatively brief, casualties relatively light, and the Nation sanctioned the war socially, veterans of Desert Shield/Storm and their families were not anticipated to suffer symptoms of trauma or re-entry stress beyond that expected in routine peacetime military deployments. However, the authors argue that the stress imposed on families by Desert Shield/Storm was not analogous to that of routine deployments. The call to duty was unexpected, disruptive, and hazardous (i.e., highly dangerous) which places it in the category of a catastrophic stressor as defined by McCubbin and Figley (1983). The deployment was a call to war, which creates unique stress beyond those experienced during peacetime deployments. The deployment also carried with it prolonged anticipation of trauma. For these reasons, the authors argue, the deployment to Desert Shield/Storm created a situation of family trauma for veterans and their families. Suggestions are offered for education, prevention and treatment for families undergoing unexpected wartime military deployments.