Valgus impacted proximal humeral fractures and their blood supply after transosseous suturing

We treated 16 patients (11 women and five men, average age 45 years), all having four-part valgus impacted fractures of the proximal humerus, with transosseous suturing. All had preoperative angiography performed 6–12 h after admission. The average impaction angle was 43°, and the mean lateral displacement of the humeral head was 1.4 mm. Postoperative angiography was performed 8–10 weeks after the operation followed by digital image processing using the segmentation technique. No statistically important reduction in the length and area of large (>0.5 mm) vessels was seen. Union was confirmed by the reduction in the length and area of small vessels (<0.5 mm). At a mean follow-up of 40 months, avascular necrosis was only found in one patient. The average Constant–Murley score was 87 (67–100) points, whereas the functional score in comparison with the unaffected shoulder was 94% (89–100%). Despite the small number of patients, transosseous fixation seems to preserve the remaining blood supply of the humeral head.

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Résumé Nous avons traité 16 malades (11 femmes et 5 hommes, dâge moyen 45 ans), présentant une fracture de lhumérus proximal à 4 fragments, impactée en valgus, avec suture trans-osseuse. Tous avaient une angiographie préopératoire exécutée 6 à 12 heures après ladmission. Langle moyen de limpaction était 43° et le déplacement latéral moyen de la tête humérale 1.4 mm. Langiographie postopératoire a été exécutée 8–10 semaines après lopération, en utilisant la technique de la segmentation. Aucune réduction statistiquement importante dans la longueur et le territoire des vaisseaux de plus de 0.5 mm na été noté. Lunion a été confirmée par la réduction de la longueur et du territoire des petits vaisseaux (<0.5 mm). À un suivi moyen de 40 mois, une seule nécrose avasculaire a été trouvé. Le score de Murley Constant moyen était 87 (67–100) points alors que le score fonctionnel en comparaison de lépaule non affectée était 94% (89–100%). En dépit du petit nombre de malades étudiés, la fixation trans-osseuse paraît conserver la vascularisation restante de la tête humérale.

     

Nickel content of as-received and retrieved NiTi and stainless steel archwires: assessing the nickel release hypothesis

This study assesses the nickel content of as-received and retrieved stainless steel and NiTi archwires alloys. New and used brand-matched, composition-matched, and cross section-matched archwires were subjected to scanning electron microscopy and energy-dispersive electron probe microanalysis. Elemental analysis was performed on three randomly selected areas, and the nickel content, expressed as ratios of Ni/Ti (in NiTi wires) or Ni/Fe (in stainless steel), was statistically analyzed with a t-test (alpha = .05). No changes were detected with respect to Ni content ratios between as-received and retrieved NiTi or stainless steel wires, suggesting an absence of nickel release. Wear and delamination phenomena on the wire surface and the formation of galvanic couple between the stainless steel wires and bracket brazing materials intraorally may modify the corrosion susceptibility of the wire alloys in clinical conditions.     

Twenty-five years' clinical experience with placental site trophoblastic tumors

OBJECTIVE: To describe 34 cases of placental site trophoblastic tumor (PSTT) treated at Charing Cross Hospital over 25 years. STUDY DESIGN: Between 1975 and 2001, 1,685 patients with gestational trophoblastic disease (GTD) were treated; 34 of them had PSTT (2%). The computer database clinical notes and the pathology reports were accessed to obtain data on this patient group. The data were subsequently analyzed using Excel computer software. RESULTS: The mean age of the group was 33 years (95% CI 25-41). The antecedent pregnancy was a full-term, normal one in 18 cases (53%), a molar pregnancy in 7 (21%) and a missed abortion in 5 (15%). The mean interval from the last pregnancy to diagnosis was 3.4 years (95% CI 1.9-4.9). The range of serum hCG concentrations at diagnosis was 0-58,000, 79% with levels < 1,000 and 58% < 500. hCG was raised in all with active disease. The most frequent presenting complaint was vaginal bleeding, in 27 cases (79%). At diagnosis, the disease was localized to the uterus in 15 (44%); there was pelvic involvement in 8 (24%) and lung secondaries in 10 (29%). All seven deaths were disease related (21%); all had lung secondaries and presented more than four years since the last pregnancy. Excluding the seven deaths, the primary treatment was surgery alone in 10 cases (37%) (8 hysterectomies and 2 dilatation and curettages); 4 had surgery followed by adjuvant chemotherapy; 5 had neoadjuvant chemotherapy followed by surgery; 1 had chemotherapy alone, and the disease recurred and was successfully rechallenged; and 5 had surgery between chemotherapy cycles. The most common regimens consisted of EMA/CO and EP/EMA. CONCLUSION: Risk factors for death include lung metastatic involvement (50%) and an antecedent pregnancy interval of four years or more (100%). In contrast, those with no extrapelvic disease or a pregnancy interval of less than four years had 100% survival. In two-thirds of patients with disease limited to the uterus, surgery alone was curative. The WHO scoring system for GTD did not correlate with this outcome. Patients with PSTT should be managed separately from those with other types of GTD, as the disease behavior is different.     

Molecular properties of HLA-DQ alleles conferring susceptibility to or protection from insulin-dependent diabetes mellitus: keys to the fate of islet beta-cells

The major histocompatibility complex Class II alleles, HLA-DQ, and the related HLA-DR, are the chief genetic elements of human type 1 diabetes. These genes code for polymorphic heterodimeric proteins, whose chief function is to trap peptide antigens in the endosome and present them on the surface of antigen-presenting cells (dendritic cells, B lymphocytes, monocytes/macrophages) to CD4(+) T helper cells. A systematic investigation of the molecular properties of HLA-DQ alleles linked to susceptibility or resistance to type 1 diabetes has shown that these properties segregate along lines of susceptibility or resistance. A correlation of these features with the function of each particular segment of the HLA-DQ molecule yields interesting insights into the possible pathways leading to type 1 diabetes. There remain, however, areas to be clarified, including mechanisms by which dominant protection is conferred by certain alleles, the interplay between HLA-DQ and the related locus HLA-DR, that also shows autoantigen-specific reactivity, and the cross-Class help delivered to CD8(+) T cells, the final effectors in pancreatic beta-cell destruction. Clarification of these issues may lead to ways to prevent diabetes in predisposed individuals already exhibiting the genetic and immunological characteristics, and perhaps a cure in those with the disease, by means of transplantation, and measures for prevention of disease recurrence.     

Sustained complete remission of metastatic dermatofibrosarcoma protuberans with imatinib mesylate

Dermatofibrosarcoma protuberans (DFSP) is a soft tissue tumor which may recur locally and rarely causes metastases to vital organs. DFSPs have specific chromosomal abnormalities involving the platelet-derived growth factor beta-chain locus (PDGFB) which may render these tumors responsive to targeted therapy with the tyrosine kinase inhibitor imatinib mesylate. A patient with locally recurrent and metastatic DFSP resistant to first-line chemotherapy was treated with imatinib mesylate 400 mg/day. The tumor was examined by a novel fluorescence in situ hybridization (FISH) method for specific rearrangements of the PDGFB locus. The patient was followed for response and toxicity by physical examination and imaging studies. FISH revealed PDGFB rearrangement indicative of multiplication of the PDGFB fusion locus within a ring chromosome. Physical examination showed response within the first month of treatment, and subsequent computed tomography and fluorodeoxyglycose positron emission tomography documented complete response to imatinib therapy. Our patient is now in sustained complete remission for 20 months with minimal toxicity. We conclude that sustained complete remission of metastatic DFSP with specific FISH abnormalities involving the PDGFB locus can be obtained with imatinib mesylate with minimal toxicity for the patient.     

Primary total-hip arthroplasty with the autophor 900-s fully porous coated stem in young patients seven to seventeen years of follow-up

A total of 233 Autophor 900-S fully porous coated stems were implanted in 220 patients with an average age of 47.5 years and an average follow-up of 13.5 years. The mean d' Aubigne-Postel score improved from 7.9 points preoperatively to 16.9 points postoperatively (P < .001). The overall result was excellent in 74.6%, good in 18.1%, fair in 5.8%, and poor in 1.5% of cases. One hip was revised for septic and two for aseptic loosening. The overall survival rate of this prosthesis was 98.1% in 17 years. The Autophor 900-S femoral stem has offered a very satisfactory clinical outcome together with considerable prosthesis longevity in the young patient population studied. It combines adequate initial stability, satisfactory subsequent bone ingrowth, smooth load transfer, and low-friction bearing surfaces.