The Prognosis in Congenital Lower Limb Hypertrophy

Twenty-eight patients with congenital total hypertrophy and ten patients with lower limb hypertrophy with congenital vascular abnormalities are reviewed. The pattern of increase in leg length discrepancy during growth and its influence on surgical management is discussed and the clinical features of the affected limbs are described. In congenital total hypertrophy the maximal increase in leg length discrepancy occurs before the age of 10 years. Those patients who have a leg length discrepancy of more than 2.5 cm at age 4 years are likely to develop significant limb overgrowth that will require eventual surgical correction. In patients with congenital vascular abnormalities the change of leg length discrepancy was variable in degree and unpredictable in pattern, even in those with similar venous anomalies. The outcome for the limb was determined by the nature of the vascular anomaly which should be accurately defined by angiography.     

严重肢体不等长50例治疗效果

目的 提高严重肢体不等长的治疗效果,减少术后并发症。方法 治疗５０例患者,比较不同平面的骨干延长,不同截骨方式,不同延长速度和频率的疗效。结果 平均延长９．５ｃｍ,其中单段最长１６ｃｍ,分段最长１８ｃｍ。     

Matching older kidneys with older patients does not improve allograft survival

Centers may restrict the use of some donor kidneys on the belief that overall graft survival is improved by giving older kidneys to older recipients and vice versa. The prevalence and the effect on graft survival (determined by death, return to dialysis, or retransplantation) of this practice among 74,297 first cadaver kidney transplantations in 1988 to 1998 was examined by using data from the United States Renal Data System. Giving older kidneys to older recipients is common; recipients > or =55 yr old received donor kidneys that were > or =55 yr old 46.2% more often than expected, but they received kidneys that were 18 to 29 yr old 33.6% less often than expected (chi(2) P < 0.0001). Both recipient and donor age have important effects on graft survival, although the effects of donor age are much stronger than those of recipient age. Compared with recipients 18 to 29 yr old, recipients > or =55 yr old were 25% (95% confidence interval, 15 to 35%, P < 0.0001) more likely to have graft failure (adjusted for donor age and other risk factors). On the other hand, donor kidneys > or =55 yr old were 78% (95% confidence interval, 58 to 99%, P < 0.0001) more likely to fail compared with kidneys 18 to 29 yr old. However, giving older kidneys to older recipients had little independent effect on graft survival, once the intrinsic effects of recipient and donor age were taken into account. For example, transplanting donor kidneys > or =55 yr old into recipients > or =55 yr old reduced the risk of graft failure only -6% (95% confidence interval, -18 to 8%, P = 0.3923) after the independent effects of donor and recipient age per se were taken into account. Thus, giving older kidneys to older recipients is a common practice that does not improve overall graft survival.     

Treatment with keratinocyte growth factor does not improve lung allograft survival in the rat

Purpose  Lung allografts are threatened by primary graft dysfunction, infections, and rejection. Novel therapies protecting pulmonary allografts are badly needed. Keratinocyte growth factor (KGF) protects the lung against a variety of injurious stimuli and exerts anti-inflammatory effects. The aim of the study was to test the potential of recombinant truncated KGF (ΔN23-KGF, palifermin) to attenuate pulmonary allograft rejection. Materials and methods  Intratracheal instillation of 5 mg/kg ΔN23-KGF was performed twice in donor rats on days 3 and 2 before explantation of the lung. In control animals, an equivalent volume of vehicle was instilled. Left lungs were transplanted in the fully allogeneic Dark Agouti to Lewis rat strain combination and in the less stringent Fischer 344 to Wistar Kyoto combination. Allograft recipients were additionally treated with ΔN23-KGF post-transplantation. Graft outcome, leukocytic infiltration, and major histocompatibility complex (MHC) class II antigen expression was analyzed. Results  In both rat strain combinations, ΔN23-KGF treatment did not improve pulmonary allograft outcome. Graft infiltration by macrophages and T lymphocytes remained unchanged. In addition, we demonstrated that MHC class II antigens were more abundant in KGF-treated allografts compared to control-treated grafts, which probably results in an increased alloreactivity. Conclusion  In conclusion, intratracheal ΔN23-KGF treatment is not effective to prevent acute pulmonary allograft rejection.     

Monitoring of bone turnover markers does not improve persistence with ibandronate treatment

ObjectiveTo assess if the use of biological marker of bone resorption (CTX) feedback is a mean to improve persistence on monthly oral ibandronate.MethodsOne year prospective multicenter study using a cluster randomisation design with physicians as randomized units into two groups, A and B; in group B, physicians used results of CTX and two standardized messages according to CTX changes from baseline: suboptimal if decrease less than 30% at week 6, positive otherwise. In group A, the follow-up was standard of care. Patients were postmenopausal women, initiating a treatment with ibandronate 150 mg monthly. They were blinded to the study hypotheses and outcome. The outcome was the proportion of patients persistent at 1-year visit.ResultsEighty-eight physicians were randomized in group A and included 346 patients, 75 in group B included 250 patients. The persistence at 1-year was high and not different between the two groups (75.1 and 74.8% P = 0.932). There was no difference in the proportion of persistent patients according to the message delivered in the group of patient with CTX information: 77.4 and 74.8% in patients with a suboptimal or positive message respectively.ConclusionThis study failed to demonstrate that supporting monitoring of CTX could improve persistence to ibandronate treatment in postmenopausal osteoporosis.Key messagesPersistence is a strong determinant of anti-osteoporotic treatments efficacy. Monitoring of bone markers is not a mean to improve persistence of an oral bisphosphonate. There is a discrepancy between levels of persistence in clinical studies and real life.     

干骺端潜行截骨延长288例

目的;介绍一种治疗肢体不等长的新方法。方法：应用自行研制的“针锯”潜行截骨,用自行研制的“多平面双轨多功能延长器”对短肢进行缓慢延长,使双下肢得以平衡。结果;288例肢体不等长患者,均达到所需延长长度,最短延长3cm,最长11.5cm,平均4.6cm。功能恢复满意。结论：干骺端潜行截骨延长方法安全,可靠,无骨不连接,骨萎缩和迟缓连接等并发症,不需要作内固定和植骨,是肢体延长的一种好方法。     

股骨下端“L”形截骨一次性和逐渐性相结合延长治疗股骨短缩畸形

目的 解决一次性延长因血管、等并发症难以达到延长目的，而逐渐性延长治疗时间持续太长等问题。方法 肌下干骺端行“Ｌ”形坎骨，术中延长２￣３ｃｍ，剩余部分术后继续逐渐延长。结果 １８例延长的和蔗为３．０￣８．５ｃｍ。步态正常者９例，膝关节活动正常８例。平均住院日为３４．５天，远低于逐渐性延长组５６．７天。结论一瓷生和逐渐性相结合延长的方法并发症少、治疗疗程明显缩短，最较理想的截骨延长方法。     

The Impact of Leg Length Discrepancy on Patient Satisfaction and Functional Outcome Following Total Hip Arthroplasty

A series of 191 patients undergoing THA with a standardised stem were studied. The effect of leg length discrepancy (LLD) on patient function (Oxford Hip Score), health measures (Short Form 12) and satisfaction (Self-Administered Patient Satisfaction Scale) at a mean 3.8 years of follow up (range 3.3 to 4.9) is reported. 8.9% of cases had shortening, 0.5% no LLD and 90.6% had lengthening. In 21.5% the LLD was more than 10 mm, in 37.1% 5–10 mm, and in 40.9% 0–5 mm. There was no significant difference in patient reported outcome measures (PROMs) according to LLD. Correlation of recorded measurements between multiple observers was excellent (0.93). LLD following total hip arthroplasty remains common but in this series, was not correlated with PROMs.     

The morphologic characteristics of nerve shortening following traumatic bone loss

Little is known about peripheral nerve shortening secondary to joint contracture or traumatic bone loss. We used the rat sciatic nerve as a model to study nerve shortening secondary to leg shortening. Nerve shortening was induced by surgically removing 16 mm of the femur. The histology of the ipsilateral and contralateral (control) sciatic nerves were compared at 1 h, 3 weeks, and 6 weeks. Transverse semithin sections of sciatic nerve were prepared and examined; single fibers also were teased from the nerve for study. The epineurium was shortened about 25% at 6 weeks. Axonal diameter was unchanged at 1 h, but increased over time, and was 0.68 µm larger than controls at 6 weeks (p < 0.05). In teased‐fiber preparations, internodal length decreased 2.3% at 6 weeks, but not significantly. Peripheral nerve shortening secondary to leg shortening shortens the epineurium, but does not effect on internodal length. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 472–476, 2009     

Pre-transplant histology does not improve prediction of 5-year kidney allograft outcomes above and beyond clinical parameters

Pre-implant kidney biopsy is used to determine suitability of marginal donor kidneys for transplantation. However, there is limited data examining the utility of pre-implant histology in predicting medium term graft outcome. This retrospective study examined kidney transplants over a 10-year period at a single center to determine if pre-implant histology can identify cases of eGFR ≤35?ml/min/1.73m² at 5 year follow up beyond a clinical predictive logistic regression model. We also compared outcomes of dual kidney transplants with standard single kidney transplants. Of 1195 transplants, 171 received a pre-implant kidney biopsy and 15 were dual transplants. There was no significant difference in graft and patient survival rates. Median eGFR was lower in recipients of biopsied kidneys compared with standard kidney transplants (44 vs. 54?ml/min/1.73m², p?2, p?=?.64). Glomerular sclerosis (p?=?.05) and Karpinski Score (p?=?.03) were significant predictors of eGFR at 5-years in multivariate analysis but did not improve discrimination of eGFR ≤35?ml/min/1.73m² at 5-years beyond a clinical prediction model comprising donor age, donor hypertension and terminal donor creatinine (C-statistic 0.67 vs. 0.66; p?=?.647). Pre-implant histology did not improve prediction of medium-term graft outcomes beyond clinical predictors alone. Allograft function of dual transplant kidneys was similar to standard transplants, suggesting that there is scope to increase utilization of kidneys considered marginal based on histology.     

The Impact of Leg Length Discrepancy on Clinical Outcome of Total Hip Arthroplasty: Comparison of Four Measurement Methods

In a single-surgeon series of 119 patients with unilateral primary uncemented total hip arthroplasty, four leg-length discrepancy measurement methods (absolute, relative, trochanteric, standardized-trochanteric) were analyzed for their impact on WOMAC score, Oxford Hip Score and self-perceived leg-length discrepancy. After adjustment for age, gender and BMI, postoperative WOMAC scores correlated only with clinical absolute measurements of leg elongation (P = 0.05). Self-perceived leg-length discrepancy corresponded best to the clinically measured relative leg-length discrepancy (11 mm perceived vs. 7 mm unperceived; P = 0.04) while there was no significant correspondence with radiographic measurements or leg elongation magnitudes. Within the < 10 mm range of mean postoperative leg length discrepancy in the studied series, its impact on the overall clinical satisfaction was detectable but not considerable.     

Primary bone grafting does not improve the results in severely displaced distal radius fractures

We prospectively randomised 45 patients ages 20-70 years with distal radius fractures of Older type III and IV to one of two treatment groups. One group was treated with closed reduction, primary bone grafting, and external fixation for 3 weeks, followed by a plaster cast that allowed volar flexion, for an additional 3 weeks. The other group was treated with closed reduction and external fixation for 6 weeks. The functional and radiographic results were evaluated. There was no difference between the two groups in either clinical or radiographic outcome. We do not recommend external fixation and primary bone grafting as a routine method in these fractures.     

Femoral Pinless Length and Offset Measurements During Computer-Assisted,Minimally Invasive Total Hip Arthroplasty

We asked whether the intraoperative assessment of leg length (LL) and offset (OS) change would be accurate using a novel pinless femoral reference system during unilateral minimally invasive THA in 50 patients with a mean age of 60 years (48–79). LL and OS change measured at surgery was compared with LL/OS change as measured on magnification-corrected preoperative and postoperative radiographs by two blinded examiners. The radiographic evaluation showed a high inter-rater reliability (r > 0.80 for all assessments). The mean differences (± 95% limits of agreement) between navigation and radiographic measurements on the treated side were + 0.4 mm (± 3.6) for LL and − 1.0 mm (± 3.9) for OS. Femoral pinless navigation technology represents a feasible assistance in THA.     

Early dynamization by reduced fixation stiffness does not improve fracture healing in a rat femoral osteotomy model

Dynamization of fracture fixation is used clinically to improve the bone healing process. However, the effect of early dynamization remains controversial. This study evaluated the effect of early dynamization, by reduced stiffness of fixation on callus stiffness and size after 5 weeks of healing in a rat diaphyseal femoral osteotomy. An external unilateral fixator allowed either a rigid (R‐group; n = 8) or a flexible (F‐group; n = 8) fixation. The dynamized group (D‐group: n = 8) had a rigid fixation for 1 week, and then a flexible fixation for the remaining 4 weeks. The pre‐ and postoperative activity of the rats was measured. After 5 weeks, the rats were sacrificed, and healing was evaluated by biomechanical and densitometric methods. The R‐group had a higher activity more closely approaching preoperative levels, compared to the D‐group throughout all time points measured. This difference was significant after 14 days and 21 days. The flexural rigidity of the R‐group was 82% (tested in the anterior‐posterior direction; p = 0.01) and 93% (tested in the medial‐lateral direction; p = 0.002) greater than the flexural rigidity of the D‐group. The rigid fixation led to a stiffer callus with a smaller callus volume, but better mineralized tissue in the whole callus and at the level of the osteotomy gap than the flexible or the dynamized fixation. Early dynamization did not improve healing compared to rigid or flexible fixation in a rat femoral osteotomy model. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:22–27, 2009     

应用Ilizarov外固定延长架治疗小儿下肢短缩畸形

目的总结小儿肢体延长的临床经验，探讨肢体延长中出现的并发症及其对策。方法 采用Ｉｌｉｚｒｏｖ外固定延长架对１４例小儿下肢短缩畸形进行１５侧肢体延长，其中股骨下端截骨延长３例，胫骨上端截骨延长９例，胫骨下端截骨延长２例。结果 随访１－６年，平均２年３个月。延长幅度３．０－１０．０ｃｍ，平均６．５ｃｍ。延长率达原骨长度的１２．５％＿４５．５％，平均２２．９％。     

Platelet rich plasma and fresh frozen bone allograft as enhancement of implant fixation. An experimental study in dogs.

Platelet rich plasma (PRP) is an autologous source of growth factors. By application of PRP around cementless implants alone or in combination with bone allograft chips, early implant fixation and gap healing could be improved. We inserted two porous HA coated titanium implants extraarticularly in each proximal humerus of eight dogs. Each implant was surrounded by a 2.5 mm gap. Four treatments were block randomized to the four gaps in each dog: Treatment 1: empty gap, treatment 2: PRP, treatment 3: fresh frozen bone allograft, treatment 4: fresh frozen bone allograft+PRP. PRP was prepared from each dog prior to operation by isolating the buffycoat from centrifuged blood samples. Platelet count in PRP was increased 670% compared to baseline level. Calcium/thrombin was added to degranulate platelets and form a gel. Three weeks after surgery, push-out test and histomorphometri was performed. After three weeks, the non-allografted implants had poor mechanical properties. Bone grafting significantly increased implant fixation, bone formation in the gap and bone growth on the implant surface. We found no significant effect of PRP alone or mixed with bone allograft on implant fixation or bone formation. In conclusion, we showed the importance of bone allografting on early implant fixation and bone incorporation but we found no effect of PRP. More studies are needed to investigate the effect and possible clinical applications of platelet concentrates which are now being commercialised.