Proximal osteotomy of the tibia for the treatment of genu recurvatum in adults.

Twenty-seven opening-wedge osteotomies of the proximal part of the tibia were performed in twenty-five patients who had genu recurvatum. In sixteen knees, the genu recurvatum was due entirely to osseous deformity. In the remaining eleven knees, it was due to a combination of osseous and soft-tissue deformity; in five, the deformity was predominantly osseous and in six, primarily in the soft tissues (the ligaments and capsule). The average age of the patients was twenty-three years (range, fifteen to fifty-four years). The osteotomy was proximal to the tibial tuberosity in twenty-two knees. In eighteen of these knees, the tuberosity was detached with its patellar ligament and then reattached to the proximal part of the tibia over the block of bone in the opened wedge; in the remaining four knees, the tibial tuberosity was not detached. The osteotomy was distal to the tuberosity in five knees. The patients were followed for an average of 14.5 years (range, three to thirty years). Of the eighteen knees in which the osteotomy had been proximal to the tibial tuberosity and the tuberosity had been detached and then reattached, nine (50 per cent) had a result that was excellent; five (28 per cent), good; and four (22 per cent), fair. Of the four knees in which the operation had been proximal to but without detachment of the tuberosity, one had a result that was excellent; two, good; and one, fair. Of the five knees in which the osteotomy was distal to the tibial tuberosity, one had a result that was good; three, fair; and one, poor. Of the twenty-one knees in which the deformity was entirely or predominantly osseous, eighteen (86 per cent) had an excellent or good result. None of the six knees in which the deformity was predominantly in the soft tissues had an excellent or good result. Patients in whom the deformity was not primarily osseous, and those in whom the operation was distal to the tibial tubercle, were much more likely to have a fair or poor result.     

Closed-Chest Cardiopulmonary Bypass and Cardioplegia: Basis for Less Invasive Cardiac Surgery

Background. We developed a method of closed-chest cardiopulmonary bypass to arrest and protect the heart with cardioplegic solution. This method was used in 54 dogs and the results were retrospectively analyzed.

Methods. Bypass cannulas were placed in the right femoral vessels. A balloon occlusion catheter was passed via the left femoral artery and positioned in the ascending aorta. A pulmonary artery vent was placed via the jugular vein. In 17 of the dogs retrograde cardioplegia was provided with a percutaneous coronary sinus catheter.

Results. Cardiopulmonary bypass time was 111 ± 27 minutes (mean ± standard deviation) and cardiac arrest time was 66 ± 21 minutes. Preoperative cardiac outputs were 2.9 ± 0.70 L/min and postoperative outputs were 2.9 ± 0.65 L/min (p = not significant). Twenty-one-French and 23F femoral arterial cannulas that allowed coaxial placement of the ascending aortic balloon catheter were tested in 3 male calves. Line pressures were higher, but not clinically limiting, with the balloon catheter placed coaxially.

Conclusions. Adequate cardiopulmonary bypass and cardioplegia can be achieved in the dog without opening the chest, facilitating less invasive cardiac operations. A human clinical trial is in progress.     

Direct comparison of umbilical cord blood versus bone marrow-derived endothelial precursor cells in mediating neovascularization in response to vascular ischemia.

Endothelial precursor cells (EPCs) cultured from adult bone marrow (BM) have been shown to mediate neovasculogenesis in murine models of vascular injury. We sought to directly compare umbilical cord blood (UCB)- and BM-derived EPC surface phenotypes and in vivo functional capacity. UCB and BM EPCs derived from mononuclear cells (MNC) were phenotyped by surface staining for expression of stromal (Stro-1, CXCR4, CD105, and CD73), endothelial (CD31, CD146, and vascular endothelial [VE]-cadherin), stem cell (CD34 and CD133), and monocyte (CD14) surface markers and analyzed by flow cytometry. The nonobese diabetic/severe combined immunodeficiency murine model of hind-limb ischemia was used to analyze the potential of MNCs and culture-derived EPCs from UCB and BM to mediate neovasculogenesis. Histologic evaluation of the in vivo studies included capillary density as a measure of neovascularization. Surface CXCR4 expression was notably higher on UCB-derived EPCs (64.29%+/-7.41%) compared with BM (19.69%+/-5.49%; P=.021). Although the 2 sources of EPCs were comparable in expression of endothelial and monocyte markers, BM-derived EPCs contained higher proportions of cells expressing stromal cell markers (CD105 and CD73). Injection of UCB- or BM-derived EPCs resulted in significantly improved perfusion as measured by laser Doppler imaging at days 7 and 14 after femoral artery ligation in nonobese diabetic/severe combined immunodeficiency mice compared with controls (P<.05). Injection of uncultured MNCs from BM or UCB showed no significant difference from control mice (P=.119; P=.177). Tissue samples harvested from the lower calf muscle at day 28 demonstrated increased capillary densities in mice receiving BM- or UCB-derived EPCs. In conclusion, we found that UCB and BM-derived EPCs differ in CXCR4 expression and stromal surface markers but mediate equivalent neovasculogenesis in vivo as measured by Doppler flow and histologic analyses.     

New anatomical reference systems for the bones of the foot and ankle complex: definitions and exploitation on clinical conditions

Medial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6 and 16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degrees of success. In recalcitrant cases, surgery is often the only option. To evaluate whether ultrasound-guided injection of 15% dextrose for treatment of recalcitrant MTSS decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport. The study design was a prospective consecutive case series involving eighteen patients: fifteen male and three female; (mean age = 31.2 years) with recalcitrant MTSS. They were referred from sports injury clinics across the UK, having failed all available conservative treatment. An ultrasound-guided sub-periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of the symptomatic area. Pain was assessed using a 10-cm visual analog scale (VAS) at baseline, short-term, medium-term (mean 18 weeks), and long-term (mean 52 weeks) follow-up. Symptom resolution and return to activity were measured using a Likert scale at medium and long-term follow-up. Statistical analyses were performed using SPSS for Mac version 19.0.0 (IBM, New York, NY, US). The Shapiro-Wilk test was used to evaluate the normality of the distribution of data. Friedman’s non-parametric test was used to compare the within-patient treatment response over time. Post-hoc Wilcoxon signed-rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods. Patients reported a significant (p < 0.01) reduction in median VAS pain score at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as ‘much improved’ at medium-term follow-up and the median return to sports score was ‘returned to desired but not pre-injury level’ at medium-term and long-term follow-up. No adverse events were reported. Ultrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in MTSS. This benefit may be maintained long-term; however, more robust trials are required to validate these findings in the absence of controls. Clinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant MTSS.     

Mucocele of the paranasal sinus. CT assessment

The authors report 7 cases of mucoceles of the paranasal sinuses evaluated with plain films and CT. All patients were submitted to surgery. Five patients were affected with frontal mucoceles and 4 with sphenoid ones. In 2 cases the lesion was double. Symptoms were correlated with both site and compressive changes due to expansile growth. All cases were evaluated by means of axial and coronal pre- and post-contrast scans: a satisfactory morphological depiction of the lesion was always achieved. CT values were also calculated, and the relationship of mucocele to the adjacent structures was demonstrated. The modalities of expansile growth, the lack of enhancement in post-contrast scans, and the possible "ring sign" in cases with intracranial spread allow a correct radiological diagnosis. CT is the diagnostic method of choice for best lesion demonstration: it makes a correct diagnosis possible and allows the thorough evaluation of the involved structures for surgical planning.     

Posterior lumbar interbody fusion a mid-term review of 60 cases

It is the purpose of this study to evaluate the clinical and radiographic medium-term results of a series of 60 patients submitted to intersomatic lumbar fusion by posterior approach, using a system constituted by carbon wedges to be associated with bone grafts for intersomatic fusion, and by steel or titanium plates or bars used for posterior pedicle osteosynthesis. Satisfactory clinical results were obtained in 88.2% of cases and complete radiographic fusion in 91.4% of cases. Complications were generally observed in 8.3% of cases. In light of these results, we may consider intersomatic lumbar fusion by posterior approach a method that is perhaps aggressive, but effective in the treatment of severe lumbar spondylolysis. The use of carbon wedges brings several advantages that favor intersomatic fusion, its progressive control, and the restoration of normal lordosis of the lumbar spine.     

The Italian experience on paediatric liver transplantation: 1988-1999 report.

BACKGROUND: Liver transplantation is the treatment of choice for end-stage liver disease in both adult and paediatric patients. The Italian experience in paediatric liver transplantation during the period 1988-1999 is reported herein. PATIENTS AND METHODS: This report concerns 228 liver transplantations performed in 207 patients (100 male, 107 female, mean age 5.1+/-4.4 years) in 11 Italian centres. The mean waiting time on the transplantation list was 6.1+/-8.9 months and the main indications for the procedure were biliary atresia, inborn metabolic disorders, liver cirrhosis, liver neoplasms, Alagille syndrome, and fulminant hepatic failure. RESULTS: The cumulative survival rate was 77%, 76%, 73%, and 71% at 1, 3, 5, and 7 years. The overall prevalence of acute rejection was 54%. Survival was significantly affected by re-transplantation (p=0.0002), by United Network for Organ Sharing 4 status at transplantation (p=0.016), and, among the indications for the procedure, by fulminant hepatic failure (p=0.004). Fifty patients (24%) died during the observation period. The main causes of death were primary non-function of the graft and sepsis CONCLUSIONS: This study shows that liver transplantation in paediatric age, in Italy, is an effective procedure providing a 5-year survival rate comparable to that attained in the largest published series.