Unstable recent intracapsular femoral neck fractures in young adults: Osteosynthesis and primary valgus osteotomy using broad dynamic compression plate

Background:

Displaced intracapsular femoral neck fractures continue to be a difficult problem to treat. Various treatment modalities and their modifications have been proposed to improve the outcome. Osteosynthesis and primary valgus angulation osteotomy is one of them. Technique and outcome in a consecutive series of recent intracapsular femoral neck fractures in young adults, from a single center, is presented.

Materials and Methods:

Fifty-five patients of recent (<3 weeks old) displaced intracapsular fracture neck femur (Garden III and IV, Pauwels III, with or without comminution) in the age group 20-50 years (mean 35.4±10.4 years) were subjected to osteosynthesis and primary valgus intertrochanteric osteotomy using contoured broad dynamic compression plate (DCP). The patients were followed up from two to six years (mean 4.6 years).

Results:

Fifty-one fractures united by six months of the index procedure (92.7% union range). Avascular necrosis (AVN) developed in six patients (11%). The other complications were shortening (six), coxa vara (two), infection (two) and delayed union at osteotomy site (one). Excellent results were achieved in 48, good/fair in four and poor in three patients.

Conclusion:

Osteosynthesis with cancellous screw and primary valgus intertrochanteric osteotomy stabilized by a contoured broad DCP is a simple, easy to perform, biological treatment. Failure in a particular case can be treated with any appropriate second procedure.

Level of Evidence:

IV     

Local control after craniospinal irradiation,intensity‐modulated radiotherapy boost,and chemotherapy in childhood medulloblastoma

BACKGROUND:

The current study was conducted to determine whether the use of cochlear‐sparing intensity‐modulated radiotherapy (IMRT) boost results in excess local failures in children with medulloblastoma.

METHODS:

Fifty children with a median age of 7.8 years underwent resection, craniospinal irradiation (CSI), IMRT posterior fossa (PF) and/or tumor bed (TB) boost, and cisplatin‐based chemotherapy for medulloblastoma. For standard‐risk patients, the CSI dose was 18 to 23.4 grays (Gy) and was followed either by an IMRT PF boost to 36 Gy and a TB boost of 54 to 55.8 Gy (n = 29) or by an IMRT TB boost to 55.8 Gy (n = 4). For high‐risk patients, the CSI dose was 36 to 39.6 Gy followed by an IMRT PF boost to 54 to 55.8 Gy (n = 8), an IMRT PF boost to 45 Gy and a TB boost to 55.8 Gy (n = 2), or an IMRT TB boost to 55.8 Gy (n = 7). For the TB boost, a 2‐cm margin around the surgical bed was treated in most patients.

RESULTS:

The 5‐year overall and progression‐free survival rates (±standard deviation) were 72% ± 6.6% and 68.3% ± 6.8%, respectively, for all patients; 77.8% ± 7.4% and 75.1% ± 7.6%, respectively, for standard‐risk patients; and 60.8% ± 12.8% and 55.4% ± 12.8%, respectively, for high‐risk patients. The 5‐year PF control rate was 90.5% ± 4.6%. TB failures occurred in 3 patients (including 2 patients who had distant failure), whereas an isolated non‐TB PF failure occurred in 1 patient.

CONCLUSIONS:

The use of IMRT was associated with excellent local control and did not result in excess PF failures outside of the TB. Cancer 2011. © 2010 American Cancer Society.     

Cigarette smoking and the risk for cartilage loss and knee pain in men with knee osteoarthritis

OBJECTIVE: To examine the effects of smoking on cartilage loss and pain at the knee in individuals with knee osteoarthritis. METHODS: 159 men with symptomatic knee osteoarthritis who participated in a 30-month, prospective, natural history study of knee osteoarthritis were examined. The more symptomatic knee was imaged using magnetic resonance imaging (MRI) at baseline, and again at 15 and 30 months of follow-up. Cartilage was scored using the Whole-Organ MRI Score semiquantitative method at the medial and lateral tibiofemoral joints and at the patellofemoral joint. At baseline and follow-up visits, the severity of knee pain was assessed using a Visual Analogue Scale pain score (0-100 mm). RESULTS: Among the 159 men, 19 (12%) were current smokers at baseline. Current smokers were younger (mean (standard deviation (SD)) age 62 (9) v 69 (9) years) and leaner (mean (SD) body mass index (BMI): 28.9 (3.2) v 31.3 (4.8) kg/m(2)) than men who were not current smokers. When adjusted for age, BMI and baseline cartilage scores, men who were current smokers were found to have an increased risk for cartilage loss at the medial tibiofemoral joint (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.0 to 5.4) and the patellofemoral joint (OR 2.5, 95% CI 1.1 to 5.7). Current smokers also had higher adjusted pain scores at baseline (60.5 v 45.0, p<0.05) and at follow-up (59.4 v 44.3, p<0.05) than men who were not current smokers. CONCLUSIONS: Men with knee osteoarthritis who smoke sustain greater cartilage loss and have more severe knee pain than men who do not smoke.     

The validity of different definitions of radiographic worsening for longitudinal studies of knee osteoarthritis

Several definitions have been used to characterize radiographic worsening of knee osteoarthritis in longitudinal studies, yet a valid definition with maximal power to detect differences between groups is not known. We used serial radiographs from the Framingham Osteoarthritis Study to compare five dichotomous definitions according to construct validity (strength of association) and discriminant power (power to reject null hypotheses of no difference) for 1) known risk factors for knee osteoarthritis, and 2) development of new knee pain. For risk factors: definitions that included scores for osteophytes (bone spurs) showed good construct validity and discriminant power; a definition using the Kellgren and Lawrence grade of overall knee osteoarthritis was conservative with good construct validity but low discriminant power; a definition based solely on ordinal assessment of joint space narrowing had weak construct validity and low discriminant power. All definitions had comparably strong associations with the development of new knee pain. Similar associations with new knee pain were found when the analysis was confined to either knees with no osteoarthritis at baseline or knees with prevalent osteoarthritis, with increased standard errors for prevalent osteoarthritis. Use of any of these definitions, other than joint space narrowing alone, would permit detection of associations with most known risk factors. Definitions incorporating both osteophytes and joint space narrowing offer the most precise estimation of the association of risk factors with disease worsening.     

Antimycobacterial Evaluation of Fifteen Medicinal Plants in South Africa

Fifteen plant species were collected from the Nelspruit Botanical Garden based on a list of plants provided by Phytomedicine Programme at the University of Pretoria and their ethnopharmacological information. Hexane, dichloromethane (DCM), acetone and methanolic extracts were screened for antimycobacterial activity against Mycobacterium smegmatis. The acetone extract of Milletia stulhimannii was the most active, showing activity against Mycobacterium smegmatis with minimum inhibitory concentration (MIC) value of 0.13 mg/ml. Acetone extracts for all plants had lower MIC values ranging between 0.11–1.25 mg/ml against M. smegmatis. Milletia stulhimannii, Albizia gummifera, Xanthocercis zambesiaca and Barringtonia racemosa have shown great potential as anti-tuberculosis agents. They were active against M. smegmatis with average MIC values of acetone extracts of 0.13 mg/ml.     

Increase in bone marrow lesions associated with cartilage loss: a longitudinal magnetic resonance imaging study of knee osteoarthritis

OBJECTIVE: Although bone marrow lesions (BMLs) are powerful predictors of joint space loss as visualized on radiographs, the natural history of these lesions, their relationship to cartilage loss, and the association between change in these lesions and cartilage loss are unknown. These questions were tested using longitudinal magnetic resonance imaging (MRI) data in a natural history study of symptomatic knee osteoarthritis (OA). METHODS: MRI of the knee was performed at baseline, 15 months, and 30 months in 217 patients with primary knee OA (122 men, 95 women; mean +/- SD age 66.4 +/- 9.4 years). To assess mechanical alignment, long-limb films were obtained at 15 months. Subchondral bone marrow abnormalities, graded in the medial and lateral tibiofemoral joints, were defined as poorly marginated areas of increased signal intensity in the marrow on fat-suppressed, T2-weighted images. Cartilage morphologic features in the medial and lateral tibiofemoral joints were scored at all time points using a semiquantitative scale. For each of the medial and lateral compartments, generalized estimating equations were used to evaluate the longitudinal relationship of tibiofemoral BMLs to the tibiofemoral cartilage score, with adjustment for malalignment. RESULTS: Fifty-seven percent of knees had BMLs at baseline, of which 99% remained the same or increased in size at followup. Knee compartments with a higher baseline BML score had greater cartilage loss. An increase in BMLs was strongly associated with further worsening of the cartilage score. Enlarging or new BMLs occurred mostly in malaligned limbs, on the side of the malalignment (e.g., new medial BMLs in varus-aligned knees). The association of BML change with medial tibiofemoral cartilage loss was not significant after adjusting for alignment. CONCLUSION: Lesions of the bone marrow are unlikely to resolve and often get larger over time. Compared with BMLs that stay the same, enlarging BMLs are strongly associated with more cartilage loss. Furthermore, any change in BML is mediated by limb alignment.     

Periods of Highly Synchronous,Non‐Reentrant Endocardial Activation Cycles Occur During Long‐Duration Ventricular Fibrillation

Periods of Highly Organized Activation During VF Background: Little is known about long‐duration ventricular fibrillation (LDVF), lasting 1–10 minutes when resuscitation is still possible. Methods and Results: To determine global left ventricle (LV) endocardial activation during LDVF, 6 canines (9.5 ± 0.8 kg) received a 64‐electrode basket catheter in the LV, a right ventricular (RV) catheter, and a 12‐lead electrocardiogram (ECG). Activation sequences of 15 successive cycles after initiation and after 1, 2, 3, 5, 7, and 10 minutes of LDVF were determined. Early during VF, LV endocardial activation was complex and present throughout most (78.0 ± 9.7%) of each cycle consistent with reentry. After 3–7 minutes of LDVF in 5 animals, endocardial activation became highly synchronized and present for only a small percentage of each cycle (18.2 ± 7.7%), indicating that LV endocardial reentry was no longer present. During this synchronization, activations arose focally in Purkinje fibers and spread as large wavefronts to excite the Purkinje system followed by the subendocardial working myocardium. During this synchronization, the ECG continued to appear irregular, consistent with VF, and LV cycle length (183 ± 29 ms) was significantly different than RV cycle length (144 ± 14 ms) and significantly different than the LV cycle length when synchronization was not present (130 ± 11 ms). Conclusion: After 3–7 minutes of LDVF, a highly organized, synchronous, focal LV endocardial activation pattern frequently occurs that is not consistent with reentry but is consistent with triggered activity or abnormal automaticity in Purkinje fibers. The ECG continues to appear irregular during this period, partially because of differences in LV and RV cycle lengths. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1266‐1273, November 2010)     

Critical appraisal of the revised Ghent criteria for diagnosis of Marfan syndrome

Radonic T, de Witte P, Groenink M, de Bruin‐Bon RACM, Timmermans J, Scholte AJH, van den Berg MP, Baars MJH, van Tintelen JP, Kempers M, Zwinderman AH, Mulder BJM. Critical appraisal of the revised Ghent criteria for diagnosis of Marfan syndrome. Marfan syndrome (MFS) is a connective tissue disorder with major features in cardiovascular, ocular and skeletal systems. Recently, diagnostic criteria were revised where more weight was given to the aortic root dilatation. We applied the revised Marfan nosology in an established adult Marfan population to define practical repercussions of novel criteria for clinical practice and individual patients. Out of 180 MFS patients, in 91% (n = 164) the diagnosis of MFS remained. Out of 16 patients with rejected diagnosis, four patients were diagnosed as MASS (myopia, mitral valve prolapse, borderline non‐progressive aortic root dilatation, skeletal findings and striae) phenotype, three as ectopia lentis syndrome and in nine patients no alternative diagnosis was established. In 13 patients, the diagnosis was rejected because the Z‐score of the aortic root was <2, although the aortic diameter was larger than 40 mm in six of them. In three other patients, the diagnosis of MFS was rejected because dural ectasia was given less weight in the revised nosology. Following the revised Marfan nosology, the diagnosis of MFS was rejected in 9% of patients, mostly because of the absence of aortic root dilatation defined as Z‐score ≥2. Currently used Z‐scores seem to underestimate aortic root dilatation, especially in patients with large body surface area (BSA). We recommend re‐evaluation of criteria for aortic root involvement in adult patients with a suspected diagnosis of MFS.