Disc herniation in the lumbar spine during growth: Long-term results of operative treatment in 18 patients

We studied 18 patients who had undergone surgery for herniated lumbar discs between the ages of 11 and 17 years. The inclusion criteria for girls was an age of 15 years or below and for boys 17 or below at surgery. The mean follow-up time was 10 years and the clinical outcome was good. Age at surgery and length of the follow-up had no effect on the result. The radiological disc height at follow-up did not correlate with the follow-up time or age of the patient at operation. MRI scans at follow-up from ten patients operated at less than 15 years of age revealed multilevel disc degeneration but favourable clinical results.     

Twenty-four-hour ambulatory blood pressure profiles in pediatric patients after renal transplantation

Ambulatory blood pressure monitoring was applied in 27 pediatric patients aged 6.3 – 24.3 (median 15.0) years who had been transplanted 1.5 – 8.4 years previously. Daytime values were compared with the mean of 10 concomitant casual blood pressure recordings. At the time of the study, antihypertensive drugs were given to 17 patients. Inulin clearance ranged from 18 to 116 (median 66) ml/min per 1.73 m². Ambulatory blood pressure monitoring confirmed hypertension or normotension determined by casual blood pressure measurements in 63% of patients. The physiological nocturnal dip in blood pressure was attenuated or reversed in 8 of 27 patients. It was reduced in all 3 patients with renal artery stenosis of the graft, in 3 of 4 patients with chronic rejection, in the only patient with recurrent focal segmental glomerulosclerosis, and in 1 of 6 patients with past acute rejection. The dipping was not related to inulin clearance. In conclusion, casual blood pressure measurements do not accurately reflect blood pressure in pediatric patients transplanted more than 1.5 years previously. A reduced nocturnal dip in blood pressure may indicate an underlying renovascular or renoparenchymal pathology. Ambulatory blood pressure monitoring should regularly be applied in patients with renal transplants. Received May 23, 1995; received in revised form June 18, 1996; accepted June 20, 1996     

Stereotactic brain biopsy in AIDS

Summary In the hope of finding a treatable condition, the need for rapid diagnosis in HIV-seropositive patients with brain lesions is apparent. In order to evaluate the efficacy of stereotactic brain biopsy in AIDS patients, we retrospectively studied 25 HIV-infected patients undergoing stereotactic biopsy. Brain lesions were identified with gadolinium-enhanced MRI and/or contrastCT. Brain biopsy was performed using the system of Riechert. From 8 up to 15 small tissue samples from one or two targets were obtained in every patient. The biopsy material was examined cytologically, histologically (including electron microscopy), immunohistochemically and, in part, by animal test and polymerase chain reaction (PCR). A definite diagnosis was achieved in 92%. Diagnosis included primary central nervous system lymphoma (PCNSL) (10), toxoplasmosis (10), progressive multifocal leukoencephalopathy (2) and one case of co-existing toxoplasmosis and cytomegalovirus infection. Two biopsies were non-diagnostic. All PCNSLs showed polymorphic B-cell populations of high malignancy; accurate classification according to the Kiel classification was not possible. In 3 lymphomas Epstein-Barr nuclear antigen (EBNA) 2-mRNA could be detected by PCR and confirmed immunohistochemically by EBNA 2 expression. In 6 cases autopsy confirmed the biopsy diagnosis. Conventional histology was not sufficiently decisive for toxoplasmosis and progressive multifocal leukoencephalopathy, so that immunohistochemistry and animal tests became very important for a final diagnosis. With the help of different morphological and molecular biological techniques stereotactic brain biopsy appears to be an effective method in the diagnosis of HIV-associated brain lesions. In view of the marked radio- and chemosensitivity of PCNSLs it is mandatory to establish an early and accurate histological diagnosis for adequate treatment.     

Proteinuria and other renal functions in Wilson’s disease

Renal lesions have repeatedly been described in Wilson’s disease (WD). We investigated the excretion of total protein, albumin, low (LMW) and high molecular weight (HMW) proteins, N-acetyl-β-D-glucosaminidase (NAG), and calcium, as well as creatinine clearance, in 24-h urine samples of 41 patients with WD aged 6 – 37 (mean 17) years who had been treated for a period of 0 – 15 (mean 4.5) years with D-penicillamine (900 mg/day). The amount of all protein excreted was significantly increased compared with controls, 39% of patients presenting with total proteinuria more than two standard deviations from the mean of controls. The changes in protein excretion depended on the duration of treatment. LMW proteinuria was elevated almost exclusively in the first 2 years after the start of treatment, indicating early tubular damage. This is supported by an initially high excretion of β₂-microglobulin, NAG, and calcium. Increased excretion of HMW proteins, including albumin, persisted over longer periods, which suggests glomerular injury in some patients, possibly related to the use of D-penicillamine. Creatinine clearance remained roughly within normal limits. We propose that renal function should regularly be checked in patients with WD. Received October 26, 1995; received in revised form August 27, 1996; accepted September 20, 1996     

Reconstruction of the anterior cruciate ligament with a cyropreserved ACL allograft

Summary. The ACL in the rabbit is innervated by three types of nerve fibres. These subserve vasoconstriction, nociceptive and proprioceptive purposes. The aim of this paper was to investigate the revascularisation and reinnervation of cyropreserved ACL allografts in 22 New Zealand white rabbits. Cyropreserved grafts were used as they may excite less host immune response. Both microangiographic and immunohistochemical methods were used. We found that cryopreserved allografts exhibited little immune response, revascularisation was considerable by the 24th postoperative week and reinnervation was essentially complete by then. No mechanoreceptors were found in ACL allografts. In rabbits, the anatomical basis for the participation of ACL allografts in sensorimotor reflexes is not given before the twelfth week after transplantation.

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Résumé. Nous avons examiné par méthodes micro-angiographiques et immuno-histo-chimiques la revascularisation et l’innervation d’un allogreffon cryopréservé (os – ligament croisé antérieur – os), chez 22 lapins de Nouvelle Zélande. Au sein de la greffe, existe une hypervascularisation maximale à 6 semaines, persistante à 12 semaines et se normalisant 24 semaines après la transplantation. Le panicule adipeux du genou était une source importante pour la revascularisation du greffon. L’immuno-histo-chimie a montré la présence de 3 types de fibres nerveuses au sein du ligament croisé: des afférents sensoriels mécano-réceptifs, des afférents sensoriels nociceptifs et des efférents sympathiques vaso-moteurs. Les contr?les ont montré l’existence de plusieurs fibres des 3 types de nerf; les terminaisons sensitives étaient toutes des corpuscules de Ruffini. Il n’y avait pas de fibre nerveuse au sein de l’allogreffe du ligament croiséà 3 et 6 semaines après la transplantation. Des fibres d’aspect cicatriciel étaient détectées à 12 semaines, tandis que des contr?les plus tardifs montraient un nombre et une distribution presque normale des filets nerveux. Aucun récepteur mécanique ne fut trouvé dans l’allogreffe. Chez le lapin, les bases anatomiques de la participation sensitivo-motrice de l’allogreffe du ligament croisé antérieur n’existent pas avant la 12ème semaine après la transplantation.

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Accepted: 11 May 1995     

Transurethral collagen injection for treatment of stress urinary incontinence

Summary Minimally invasive treatment of urinary incontinence has become a subject of major interest in recent years. We examined the use of transurethral collagen injection for incontinence treatment. A total of 48 patients were selectet for this procedure from April 1993 to February 1997 – 26 male patients (19 post-RPX incontinence and 7 post-TUR incontinence) and 22 female patients (all after previous incontinence surgery) were treated by injection of collagen into the continence region. The whole group underwent an average of 1.8 sessions, and a mean collagen injection volume of 14.5 ml was delivered per session. Mean follow-up was 9.2 months. Of the female population, 68.2 % were cured or greatly improved. In the male population only 47.3 % of the post-RPX patients and 6/7 of the post-TUR patients benefited from the procedure. In males, treatment outcome depends on the degree of pretreatment incontinence, because all grade III incontinence patients did worse. Therefore we conclude: transurethral collagen injection is an interesting method in the treatment of urinary incontinence if proper patient selection is assured.      

One-stage versus two-stage lymph node dissection after investigation of sentinel lymph node in cutaneous melanoma: a comparison of complications, costs, hospitalization times, and operation times

The aim of the study was to evaluate whether complication rate, costs, operation times, and hospitalization times differed in two different patient groups: in group 1, frozen section analysis of the sentinel lymph node and lymph node dissection were carried out in the same operation. In group 2, normal investigation of the sentinel lymph node and lymph node dissection were done in a second operation. One hundred thirty-five patients with cutaneous melanoma were included. Hospitalization times, costs, complication rates, and operation times of two-stage and one-stage lymph node dissection of the draining area after detection of metastases in the sentinel lymph node were retrospectively compared. Lymph node metastasis in the sentinel lymph node was found in 23 patients. In 11 patients, removal of the sentinel lymph node and dissection of the lymph node basin was performed in the same operation. In 12 patients, a two-stage procedure was the treatment of choice. Operation times were not different in the two groups (p=0.87) while two-stage operation patients were hospitalized significantly longer (14.2 ± 9.7 vs 23.9 ± 24 days; p=0.01) and costs were significantly higher (7,836.90 ± 2,397.95 Swiss francs vs 5,279.40 ± 1,994.90 Swiss francs). In addition, more complications were found in the two-stage group.     

Lower leg overuse injuries in athletes

Achilles paratenonitis and medial tibial syndrome are the most common specific overuse injuries among athletes in Finland, and they are a problem especially in endurance sports, such as long-distance running and jogging. Conservative treatment is often successful, but if it fails operative treatment is necessary. The surgical methods developed in Finland, which are widely used in the treatment of Achilles paratenonitis and medial tibial syndrome, are presented with clinical follow-up results in this paper. The patients operated on for Achilles paratenonitis were some years older than the patients operated on for retrocalcaneal bursitis (mean 38.4 versus 32.3 years). Results after operation were excellent or good in 92.4% of 291 patients operated on for Achilles paratenonitis, 84.2% of the 63 operated on for retrocalcaneal bursitis and 79% of the 47 operated on for medial tibial syndrome. All the patients treated operatively were patients in whom conservative treatment had failed. In conclusion, operative treatment of Achilles paratenonitis or medial tibial syndrome in athletes is indicated when these complaints do not respond to any type of conservative treatment.     

Quadriceps tendon and patellar ligament: Cryosectional anatomy and structural properties in young adults

Structural tensile properties analyses of 10-mm-wide central sections of quadriceps tendon-bone (QT-B) and bone-patellar ligament (B-PL) complexes from young male donors (mean age 24.9 years, range 19–32 years) were complemented by a cryosectional analysis: each QT-B complex was composed of the segment of the quadriceps tendon with the proximal half of the patella attached, each B-PL complex was composed of the distal half of the patella with the patellar ligament attached. A servohydraulic materials testing machine was used to assess ultimate failure load of 16 unconditioned and 16 preconditioned QT-B and B-PL complexes at an extension rate of 1 mm/s. Ligaments/tendons were preconditioned during 200 cycles from 50 to 800 N at 0.5 Hz. On cryosections the quadriceps tendons were significantly longer and thicker and exhibited a significantly larger bony attachment area than the patellar ligaments. Cross-sectional areas of 10-mm-wide, full-thickness, central parts of unconditioned quadriceps tendons were significantly greater and measured 64.6±8.4 mm² with respect to the cross-sectional area of patellar ligament, measuring 36.8±5.7 mm² (P<0.0025). Ultimate failure loads for unconditioned complexes resulted at 2173±618 N for QT-B complexes and at 1953±325 N for B-PL complexes (P=0.43). Ultimate failure load values measured 2353±495 N for preconditioned QT-B complexes and 2376±152 N for preconditioned B-PL complexes, respectively (P=0.77). Despite the fact that initial testing length, area of unconditioned QT-B and B-PL complexes were significantly different, displacement at ultimate load, energy to failure and total energy were not. In terms of ultimate tensile strength, the 10-mm-wide central part of the QT-B complex compared favourably to the tensile properties of the human femur-anterior cruciate ligament-tibia complex from a comparable young age group. The evidence from anatomic, cryosectional and structural properties analyses suggests that the QT-B complex may be a valuable and versatile adjunct to the surgeon's armamentarium in reconstructive cruciate ligament surgery.