Long-term results of arthrodesis for osteoarthritis of the ankle

A bone graft in the shape of a triangular prism was taken from the anterior surface of the tibia and used in the arthrodesis in 43 joints of 42 patients with primary and secondary osteoarthritis of the ankle. The modified anterior sliding inlay graft method was used. The average period of external immobilization was 5.8 weeks (range, 27-84 days), and followup ranged from 2 years 4 months to 14 years 11 months (average, 7 years 2 months). Nonunion was detected in three (7%) patients: one patient returned to work without additional treatment, and the other two patients underwent followup surgery within 7 months, and bony union was achieved. The final rate of nonunion was 2.3%. After the operation, excellent alleviation of pain was obtained. However, dorsiflexion of the foot decreased from the preoperative average value of 10.5 degrees to the postoperative value of 4.2 degrees, and plantar flexion also decreased from the preoperative value of 24.7 degrees to the postoperative value of 14 degrees. In addition, the range of motion of the subtalar and Chopart joints gradually improved with little effect on daily living activities. The most appropriate position of arthrodesis of the ankle appears to be in the neutral position between dorsal and plantar flexion. In addition, the varus and valgus angle of the hindfoot should be in a neutral or slightly valgus position. Degenerative arthritis developed and advanced in the subtalar joint in 32.5% of the patients, and these degenerative changes were exacerbated in many patients if such changes were present before surgery. Tibial stress fracture occurred in two (4.7%) patients as a complication that was specific to the current surgical method. Thus, the surgical procedure was modified to prevent the onset of tibial stress fracture.

[A case of gastric stromal tumor with chest pain and diaphragm elevation]

A 66-year-old woman presented with left chest pain. Left pleural effusion was seen on a chest X-ray film and a large mass disclosed by chest computed tomography. However, the patient refused to undergo a recommended operation. Six months later, she was admitted without any symptoms. A huge (18 cm diameter) mass was detected by magnetic resonance imaging (MRI), and consisted of heterogeneous solid and cystic components. Angiography and endoscopic sonography disclosed a suspected abdominal tumor, which was resected by thoracolaparotomy. Gastric stromal tumor was diagnosed on the basis of histological findings. Chest pain and pleural effusion are rare as initial clinical symptoms of such tumors.

Transfer of a pedicled venous flap containing perivenous areolar tissue and nerve: an experimental study

In this paper, we evaluated experimentally the feasibility of transferring a pedicled venous flap with perivenous areolar tissue into an ectopic site and investigated the role of each vein, the perivenous areolar tissue and nerve in the viability of pedicled venous flaps. Three groups of flaps were created using a rabbit-ear model: Group 1 (n = 11), containing perivenous areolar tissue and a draining vein; Group 2 (n = 10), perivenous areolar tissue, a draining vein and nerve; Group 3 (n = 10), only perivenous areolar tissue. Macroscopic, angiographic and histological assessments were performed 14 days after transfer. The total survival areas including superficial necrosis of Groups 1, 2 and 3 were 52.7%, 82.5% and 0%, respectively. There were significant differences in mean survival area and mean total survival area including superficial necrosis between Group 1 and Group 2 (P < 0.05). In contrast, all flaps in Group 3 became necrotic. These data suggest that a preserved vein is the necessary condition, and additional arterial flow through the preserved nerve and a small vascular network within the areolar tissue may play an important role in flap survival.

Osteogenic phenotype expression of allogeneic rat marrow cells in porous hydroxyapatite ceramics

Porous hydroxyapatite (HA) ceramics were combined with either allogeneic (ACI) or isogeneic (Fischer 344) rat marrow cells and implanted in subcutaneous sites of Fischer rats. FK506 as an immunosuppressant or saline was administered to the recipient rats. The implanted marrow/HA composites were harvested on day 28 and analyzed for bone-forming capability by determining osteoblastic phenotype expression levels of protein synthesis and gene expression. The alkaline phosphatase (ALP) activity and osteocalcin (OC) contents were very low and mRNAs (Northern blot analysis) were not detected in the allografts without FK506. However, high activity of ALP and high content of OC were found and mRNAs were detected in the allografts with FK506 and in the isografts (with and without FK506). This analysis indicates the osteogenic potential of allogeneic marrow cells in the presence of FK506. The histologic sections revealed that allografts without FK506 did not show bone formation but did show the infiltration of many small cells in the ceramics indicating an immunologic reaction, however, the allografts with FK506 and the isografts (with and without FK506) showed consistent de novo bone formation on the HA pore surface. These results indicate that FK506 can suppress the immunologic reaction in the allografts and induce a favorable conditions to support osteoblastic differentiation of allogeneic rat marrow stromal stem cells on the surface of HA ceramics. Therefore, our study suggests the feasibility of clinical transplantation of allogeneic bone marrow for a selected bone graft in applications using adjuvant systemic immunosuppression.

Overexpression of matrix metalloproteinase (MMP)-9 correlates with metastatic potency of spontaneous and 4-hydroxyaminoquinoline 1-oxide (4-HAQO)-induced transplantable osteosarcomas in rats

In the present experiment, the expression of matrix metalloproteinase (MMP)-2 and MMP-9, key proteins in the MMP family, and the tissue inhibitors of metalloproteinase (TIMP)-1 and TIMP-2, antagonistic proteins against MMP-2 and MMP-9, respectively, were investigated by Northern blot analysis in rat transplantable osteosarcomas with high and low metastatic potencies. Two transplantable osteosarcomas, one induced with the carcinogen, 4-hydroxyaminoquinoline 1-oxide (4-HAQO) (COS, chemical carcinogen-induced osteosarcoma), and the other, a spontaneous lesion (SOS, spontaneous osteosarcoma), were repeatedly transplanted from lung nodules to generate lines with high metastatic potency, C-SLM (chemical carcinogen-induced osteosarcoma, selected lung metastatic lesions) and S-SLM (spontaneous osteosarcoma, selected lung metastatic lesions), respectively. MMP-9 was overexpressed in both S-SLM and C-SLM, and TIMP-2 in the case of S-SLM. Neither MMP-2 nor TIMP-1 was overexpressed in either of the transplantable osteosarcomas with high metastatic potentials. The active form MMP-9, studied by zymography, increased in S-SLM and C-SLM but not in SOS and COS. MMP-9 mRNA expression was highly correlated with the gelatinolytic activity of active form MMP-9 (r = 0.85, P < 0.0001) and with the activation ratio of MMP-9 (r = 0.83, P < 0.0001). However, the active form MMP-2 was not detectable in all cases. These results suggest that overexpression of MMP-9 mRNA is one of the essential factors in the acquisition of metastatic potential in rat transplantable osteosarcomas.

Human marrow cells-derived cultured bone in porous ceramics

From four patients (mean age, 60 years; range 51-76 years), 3 ml of bone marrow was collected from the ilium. The marrow was cultured to concentrate and expand the marrow mesenchymal cells on a culture dish. The cultured cells were then subcultured either on another culture dish or in porous areas of hydroxyapatite ceramics in the presence of dexamethasone and beta-glycerophosphate (osteogenic medium). The subcultured tissues on the dishes were analyzed by scanning electron microscopy (SEM), and subcultured tissues in the ceramics were implanted intraperitoneally into athymic nude mice. Vigorous growth of spindle-shaped cells and a marked formation of bone matrix beneath the cell layers was observed on the subculture dishes by SEM. The intraperitoneally implanted ceramics with cultured tissues revealed thick layer of lamellar bone together with active osteoblasts lining in many pore areas of the ceramics after 2 months. The in vitro bone formation on the culture dishes and in vivo bone formation in porous ceramics were detected in all cases. These results indicate that we can assemble an in vitro bone/ceramic construct, and due to the porous framework of the ceramic, the construct has osteogenic potential similar to that of autologous cancellous bone. A significant benefit of this method is that the construct can be made with only a small amount of aspirated marrow cells from aged patients with little host morbidity.

Al2O3 doped apatite-wollastonite containing glass ceramic provokes osteogenic differentiation of marrow stromal stem cells

Fresh marrow cells were obtained from femora of Fischer rats and cultured in a medium containing 15% fetal calf serum (FCS) until confluence. After trypsinization, cells were subcultured at a cell density of 100 x 10(3)/35-mm well in the presence of FCS, beta-glycerophosphate, and ascorbic acid phosphate on four different culture substrata. The period of subculture was 2 weeks; the substrata used were the culture dish, apatite-wollastonite containing glass ceramic (AW), hydroxyapatite coated AW (HA/AW), and Al2O3 doped AW (Al/AW). The HA coating was attained by the incubation of AW in simulated physiological solution. The glass matrix of AW and HA/AW contained MgO, CaO, P2O5, and SiO2; Al/AW contained Al2O3 in addition to these components. The subculture on Al/AW substratum showed many alkaline phosphatase (ALP) positive nodules and the highest ALP activity. On a Northern blot analysis the housekeeping gene of beta-actin mRNA was evenly detected from the cells cultured on all substrata; however, bone-specific osteocalcin mRNA was only detected from the cells on Al/AW. These results indicate that Al/AW provokes the osteoblastic differentiation of marrow stromal stem cells.

Inhibition of spontaneous rat osteosarcoma lung metastasis by 3S-[4-(N-hydroxyamino)-2R-isobutylsuccinyl]amino-1-methoxy-3,4-dihydroc arbostyril, a novel matrix metalloproteinase inhibitor

In the present experiment, we examined the effects of OPB-3206, 3S-[4-(N-hydroxyamino)-2R-isobutylsuccinyl]amino-1-methoxy-3,4- dihydrocarbostyril, a novel metalloproteinase inhibitor, on the growth and metastasis of transplantable osteosarcomas (spontaneous osteosarcoma, selected lung metastatic lesions; S-SLM), which were previously established in rats. OPB-3206 inhibited the activities of interstitial collagenase, gelatinases A and B, and stromelysin in vitro. After oral administration to rats, its serum concentration peaked at 40 min and the drug was no longer detectable at 8 h. When OPB-3206 was orally administered at 0%, 0.1% and 0.4% in the diet for 4 weeks, starting 7 days after subcutaneous transplantation of osteosarcomas to male Fischer 344 rats, numbers of lung metastatic nodules were significantly reduced by the highest dose, while the growth of subcutaneous tumors was not affected. Zymographic analysis showed the presence of pro matrix metalloproteinase (proMMP)-2, proMMP-9 and MMP-9 activities in S-SLM. In animals fed 0.4% OPB-3206, the activity of proMMP-9 was increased, but that for MMP-9 had become undetectable. The results thus suggest that OPB-3206 selectively inhibits lung metastasis of rat transplantable osteosarcomas by inhibiting MMP-9 activation.

Clear cell change in colorectal adenomas: its incidence and histological characteristics

AIMS

The aim of our investigation was to clarify the histological characteristics and biological significance of clear cell change in colorectal adenomas. METHODS ANID RESULTS: We found three cases (0.086%) of tubular adenomas with clear cell change in a review of 3486 cases of colorectal adenoma. These three cases occurred in male patients and were located in the left-sided colon. To investigate the nature and biological significance of the clear cells, we conducted histochemical staining (periodic acid-Schiff (PAS) with or without diastase digestion, alcian blue pH 2.5) and immunohistochemical staining (using antibodies against carcinoembryonic antigen (CEA), alpha-fetoprotein, p53 protein and Ki67 antigen) and also mitotic counts. Histologically, the changed area was characterized by pyknotic and randomly arranged nuclei with PAS-negative clear and vacuolated cytoplasm. Immunoreactivity for CEA was diffuse and strong in the clear cells, but not in the tumour cells in the ordinary portion of the adenomas. The Ki67 labelling index and the mitotic activity were both higher in the clear cell portion than in the ordinary portion.

CONCLUSIONS

This is the first study to indicate the incidence of clear cell change among colorectal adenomas. It has confirmed high proliferative activity within the clear cell portion of colorectal adenomas.

Sleep complaints among the elderly: results from a survey in a psychogeriatric outpatient clinic in Brazil

BACKGROUND

Sleep complaints are frequent in old age. These difficulties are often associated with health-related problems, drug consumption, and the presence of mental disorders. Nonetheless, only sparse information is available on the clinical characteristics of elderly persons with insomnia.

AIMS

(a) To evaluate the prevalence of sleep problems among the elderly assessed in a psychogeriatric outpatient clinic; (b) to evaluate the association between the use of sleep tablets and sleep difficulties in this sample of patients.

METHODS

One hundred eighteen consecutive subjects were recruited from a psychogeriatric outpatient service in São Paulo, Brazil. Their sleep pattern was systematically assessed with the "sleep inventory," a questionnaire consisting of 31 items that evaluate a number of sleep-related features. Clinical diagnoses followed the ICD-10 clinical descriptions and diagnostic guidelines. The number of drugs consumed by patients was also recorded.

RESULTS

Sleep complaints were highly prevalent (59.3%), with early-morning awakening and nightmares being more frequent among patients with a depressive disorder. The use of sleep tablets was reported by 37.3% of subjects, and was associated with subjective sleep difficulties (odds ratio [OR] = 7.13, p = .008), difficulties falling asleep (OR = 7.33, p = .021), and frequent awakening during the night (OR = 7.10, p = .040) in a logistic regression analysis.

CONCLUSION

Sleep dissatisfaction is frequent among psychogeriatric outpatients. Subjects taking hypnotic drugs have more sleep-related complaints than those who do not. The clinical use of hypnotics may not be very effective for the treatment of sleep-related problems in the elderly. There is an urgent need for systematic prospective controlled studies to assess the efficacy and safety of the various forms of treatment of insomnia in old age.

CT demonstration of fibrous stroma in chronic pancreatitis: pathologic correlation

Fibrous stroma found in two patients with chronic pancreatitis was investigated. The helical CT-pathologic correlation confirmed that fibrous stroma found in the subcapsular zone of the pancreatic parenchyma corresponded to the area that was identified as a hypodense zone in the early phase by spiral CT and became isodense with the internal parenchyma in the delayed phase. These CT findings have an important implication for the diagnosis of chronic pancreatitis.

Delay in administration of CDDP until completion of AGM-1470 treatment enhances antimetastatic and antitumor effects

The efficacy of cis-diammine dichloroplatinum (CDDP) therapy in combination with continuous administration of angiogenesis inhibitor o-(chloroacetyl-carbamoyl) fumagillol (AGM-1470) was evaluated experimentally using a transplantable rat osteosarcoma line previously established in our laboratory. AGM-1470 (2.5 mg/kg body weight/week) was administered by Alzet osmotic pumps for 2 weeks starting from 7 days after tumor inplantation and CDDP (1.25 mg/kg) was given on days 21 and 24. The number of lung metastatic nodules was counted and the wet weights of the primary tumors were measured 5 weeks after tumor inplantation. Values with administration of CDDP 3 days after discontinuation of AGM-1470 were significantly lower than when the two agents were coadministered (P < 0.05). This animal model should facilitate optimization of the timing of combination therapy.

[Expert systems and automatic diagnostic systems in histopathology--a review]

In this decade, the pathological information system has gradually been settled in many hospitals in Japan. Pathological reports and images are now digitized and managed in the database, and are referred by clinicians at the peripherals. Tele-pathology is also developing; and its users are increasing. However, in many occasions, the problem solving in diagnostic pathology is completely dependent on the solo-pathologist. Considering the need for timely and efficient supports to the solo-pathologist, I reviewed the papers on the knowledge-based interactive expert systems. The interpretations of the histopathological images are dependent on the pathologist, and these expert systems have been evaluated as "educational". With the view of the success in the cytological screening, the development of "image-analysis-based" automatic "histopathological image" classifier has been on ongoing challenges. Our 3 years experience of the development of the pathological image classifier using the artificial neural networks technology is briefly presented. This classifier provides us a "fitting rate" for the individual diagnostic pattern of the breast tumors, such as "fibroadenoma pattern". The diagnosis assisting system with computer technology should provide pathologists, especially solo-pathologists, a useful tool for the quality assurance and improvement of pathological diagnosis.

Marrow cell culture on poly-L-lactic acid fabrics

Bone marrow cells from rat femurs were cultured in Eagle Minimum Essential Medium containing 15% fetal calf serum until confluence. After the cells were trypsinized, they were subcultured on fabrics made of biodegradable poly-L-lactic acid for 2 weeks in the medium containing fetal calf serum, ascorbic acid phosphate, beta-glycerophosphate, and with and without dexamethasone. In the presence of dexamethasone, the fabrics showed many mineralized nodules together with cuboidal shaped cells that had osteoblastic activity, as evidenced by high alkaline phosphatase activity and the appearance of osteocalcin messenger ribonucleic acid. However, in the absence of dexamethasone, nodules did not form and many fibroblastic cells appeared with no evidence of osteoblastic activity. These results indicate the possibility of making a hybrid ligament substitute having an in vitro prefabricated bone anchor.

Detection of cracks in polyethylene components of retrieved knee joint prostheses

Subsurface cracks that had formed in polyethylene artificial knee components were observed nondestructively with a new method, scanning acoustic tomography (SAT). Standardization of the SAT observation was done by in-vitro rolling fatigue testing on an unimplanted ultra high molecular weight polyethylene (UHMWPE) knee component. Retrieved knee components were of two types; KOM (Kyocera, Kyoto, Japan) sterilized with ethylene oxide gas, and MG (Zimmer, IN, USA) sterilized with gamma-irradiation. The SAT images revealed cracks in all the retrieved components, and these existed mainly 0. 3-1.0 mm from the surface. Comparison of crack formation in each portion of the contact area of the polyethylene components showed that the middle portion of the MG type had the highest concentration of cracks. When the distribution of compressive stress on the polyethylene components was assessed by mechanical testing, the strongest compressive stress was seen in the middle portion of MG type components.

Nodular hidradenoma of the breast: report of two cases with literature review

Two cases of nodular hidradenoma of the breast with possibly different origins are reported. Case 1 is of a 58-year-old female with a breast mass in the left, outer lower-quadrant. A histogenetical origin in the skin adnexal glands was suspected due to its superficial location and immunohistochemical findings. Case 2 is of a 44-year-old male with a subareolar nodule and nipple discharge. Histological examination demonstrated that the tumor was located deep in the breast tissue, was surrounded by dilated mammary ducts and exhibited intraductal extensions, which are all features mimicking those of breast cancer. Immunohistochemical positivity against gross cystic disease fluid protein-15 was weakly identified and negativity for endoplasmic reticulum was observed. This case can be interpreted as arising in the mammary ducts. It is well known that various kinds of skin adnexal tumors arise in the breast tissue; however, nodular hidradenoma of the breast is still a rare benign neoplasm. Clinically, nodular hidradenoma of the breast tends to occur in the nipple or subareolar region of the female breast. It should be kept in mind that nodular hidradenoma may occur in mammary ducts and it should be included when differential diagnoses are made of subareolar breast tumors.

Histologic findings in polyacrylamide-coated polytetrafluoroethylene (PTFE) arterial grafts in the rat abdominal aorta

To improve cell attachment without inducing thrombogenesis, the authors coated the inner surface of polytetrafluoroethylene (PTFE) prostheses (I.D.: 1 mm; length: 10 mm; wall thickness: 0.5 mm; fibril length: 30 microm) with polyacrylamide (PAA), known to have a strong antithrombotic effect (PAA-PTFE). They implanted the prostheses into the abdominal aorta of rats, and retrieved them at intervals of up to 9 months. Graft healing was observed under light and scanning electron microscopy. All the inner surfaces of the grafts examined were barely covered with fibrin or platelets. The PAA-coated fibers had many projections, in contrast to the original PTFE prostheses. Neo-endothelium was observed to be directly attached to these structural fibers of the PAA-PTFE grafts. Restoration of the neointima was also observed in these vascular prostheses.

[Respiratory bronchiolitis-associated interstitial lung disease]

A 48-year-old man was admitted because of persistent dry cough for six months. He had been a smoker for 25 years, averaging a pack a day, and demonstrated clubbing of the fingers. Basilar fine crackles were observed in both lung fields. Chest X-ray films on admission showed diffuse reticulonodular shadows. Chest computed tomograms showed low-attenuation areas mainly in the center of the upper lung field, and ground-glass opacity, air bronchiolograms, and perivascular interstitial thickening of the peripheral vessels mostly in the lower field. A Gascintigram disclosed mild accumulation in both lungs. A transbronchial lung biopsy specimen did not reveal special features. However, a biopsy specimen obtained by thoracoscopy showed evidence of respiratory bronchiolitis, with a mononuclear inflammatory process involving respiratory bronchioles and adjacent air space, associated with mild fibrous thickening of the peribronchiolar interstitium and surrounding alveoli septa. These findings suggested that the patient had respiratory bronchiolitis-associated interstitial lung disease, the second case to be reported in Japan.

Telomerase activity correlates with growth of transplantable osteosarcomas in rats treated with cis-diammine dichloroplatinum or the angiogenesis inhibitor AGM-1470

To determine the role of telomerase activity in the growth of tumors in rats undergoing chemotherapy, a comparison of the volumes of telomerase-positive transplantable osteosarcomas was made in rats treated with the antineoplastic agent cis-diammine dichloroplatinum (CDDP) or the angiogenesis inhibitor O-(chloroacetylcarbamoyl)fumagillol (AGM-1470). Male F344 rats, 8 weeks old, received transplants of macroscopic lung metastatic nodules into the subcutaneous back space and treatment was started on day 14 thereafter. CDDP was injected i.v. at doses of 0, 0.625, 1.25 and 2.5 mg/kg body weight (b.w.) and AGM-1470 was administered at total doses of 0, 2.5, 5 and 10 mg/kg b.w. over 2 weeks by osmotic pumps, also implanted into the subcutaneous back space, but remote from the transplanted tumors. On day 28, all animals were killed for measurement of transplanted tumor size and determination of telomerase activities by telomeric repeat amplification protocol (TRAP) assay. The results showed telomerase activity to be highly correlated with the treated/non-treated (T/C) tumor size ratio (r = 0.96, P < 0.0001). In a second experiment, CDDP at 2.5 mg/kg b.w. and AGM-1470 at 10 mg/kg b.w., these being the most effective doses, were given as in the first experiment, and animals were serially killed on days 14, 21, 28, 35 and 42. Tumors in rats treated with CDDP and AGM-1470 showed 18.2% and 20.5% of the control telomerase activity on days 35 and 21, respectively, when tumor growth was inhibited. However, on day 42, the activities increased to 46.5% and 92.5%, this correlating with re-growth (r = 0.73, P < 0.0001). These results suggest that decline of telomerase activity may be involved in tumor growth retardation induced by chemotherapeutic agents. This possibility clearly warrants further mechanistic studies.

Analysis of gene expression in osteogenic cultured marrow/hydroxyapatite construct implanted at ectopic sites: a comparison with the osteogenic ability of cancellous bone

We investigated the in vivo osteogenic ability of cultured marrow cells subcultured in porous hydroxyapatite. This osteogenic ability was compared with that of cancellous bone grafts. Fresh marrow cells were obtained from young adult rat femora and cultured in a standard medium for 10 days, then trypsinized and used to make constructs of porous hydroxyapatite (HA) and cultured marrow cells. An additional 2-week culture (subculture) was performed for the construct in standard medium with and without the addition of dexamethasone (Dex). The 2-week subcultured constructs then were implanted into subcutaneous sites of syngeneic rats. These implants and the rat cancellous bone were harvested and prepared for gene expression analysis of alkaline phosphatase (ALP) and osteocalcin (OC) as well as for histological analysis. ALP and OC mRNAs could be detected in Dex-treated subcultured constructs 1 week after implantation with an increase at 2 weeks, comparable to the observation in cancellous bone. Histological analysis showed active bone formation even 1 week postimplantation. In contrast, the subcultured constructs without the addition of Dex did not show bone formation, and only small levels of ALP and OC mRNAs were found. These results indicate that the bone tissue formed by grafting the Dex-treated construct of cultured marrow cells and hydroxyapatite possesses a high osteoblastic activity comparable to that of viable cancellous bone. Thus the prefabricated osteogenic subcultured marrow/HA construct may be applicable in bone reconstructive surgery.

Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: cadaveric and clinical studies

This study was undertaken to evaluate incomplete tears of the subscapularis tendon that occur in conjunction with small or medium-sized tears of the supraspinatus tendon. Fifty-two shoulders were examined in 26 embalmed cadavers. The average age at the time of death was 76.3 years. Rotator cuff tears were observed in 32 (61.5%) shoulders. Six (11.5%) shoulders had massive rotator cuff tears and were excluded from the study, leaving 46 shoulders for study. Twenty shoulders had a tear of the supraspinatus tendon, and 17 had a tear of the subscapularis tendon. All tears of the subscapularis tendon were articular-side incomplete tears. On histologic examination most pathologic changes of the subscapularis tendon were observed on the articular side of the upper portion. Lesions of the long head of the biceps brachii were identified in 14 (30.4%) shoulders. A statistically significant correlation was found between tears of the subscapularis tendon and the presence of lesions of the long head of the biceps brachii (P=.0014). In addition, the results of preoperative magnetic resonance imaging of 15 patients (average age, 62.9 years) with a surgically confirmed diagnosis of incomplete tears of the subscapularis tendon in conjunction with tears of the supraspinatus tendon were also evaluated. Incomplete tears of the subscapularis tendon could be identified on magnetic resonance imaging as an area of high signal intensity on axial T2-weighted images in all 15 shoulders studied.

Subtalar arthrography in acute injuries of the calcaneofibular ligament

We treated 43 acute tears of the calcaneofibular ligament by operation in 43 patients after subtalar arthrography. There were 22 men and 21 women with a mean age of 22.3 years (14 to 61). Anteroposterior (AP), lateral and oblique views were obtained with the foot in 45° of internal rotation and the ankle in the neutral position. Any communication or leakage to the ankle, tendon sheaths, subcutaneous tissue and sinus tarsi was recorded. We examined an oblique view of the microrecess along the interosseous ligament and an AP view of the lateral recess just under the distal end of the fibula. We also studied a control group of 27 patients with isolated injuries of the anterior talofibular ligament without rupture of the calcaneofibular ligament.

The findings in the two groups were significantly different when examined for leakage to the ankle (p = 0.0002), to the peroneal tendon sheaths (p = 0.0347) and to the subcutaneous tissue (p = 0.0222), absence of the microrecess (p = 0.0055) and presence of the lateral recess (p = 0.0012).

Many ankle sprains which involve tearing of the calcaneofibular ligament are accompanied by injuries of the subtalar joint. Combined injuries of the anterior talofibular ligament and calcaneofibular ligament, and isolated injury of the anterior talofibular ligament should be differentiated.

Subtalar arthrography in acute injuries of the calcaneofibular ligament

We treated 43 acute tears of the calcaneofibular ligament by operation in 43 patients after subtalar arthrography. There were 22 men and 21 women with a mean age of 22.3 years (14 to 61). Anteroposterior (AP), lateral and oblique views were obtained with the foot in 45 degrees of internal rotation and the ankle in the neutral position. Any communication or leakage to the ankle, tendon sheaths, subcutaneous tissue and sinus tarsi was recorded. We examined an oblique view of the microrecess along the interosseous ligament and an AP view of the lateral recess just under the distal end of the fibula. We also studied a control group of 27 patients with isolated injuries of the anterior talofibular ligament without rupture of the calcaneofibular ligament. The findings in the two groups were significantly different when examined for leakage to the ankle (p=0.0002), to the peroneal tendon sheaths (p=0.0347) and to the subcutaneous tissue (p=0.0222), absence of the microrecess (p=0.0055) and presence of the lateral recess (p=0.0012). Many ankle sprains which involve tearing of the calcaneofibular ligament are accompanied by injuries of the subtalar joint. Combined injuries of the anterior talofibular ligament and calcaneofibular ligament, and isolated injury of the anterior talofibular ligament should be differentiated.

Hypergonadotropic hypogonadism in a 3-year-old girl with blepharophimosis, ptosis, and epicanthus inversus syndrome

We report on ovarian dysfunction in a 3-year-old girl with blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES). A gonadotropin releasing hormone test showed hyperresponses of luteinizing hormone (<0.2-->7.2 mIU/ml) and follicle-stimulating hormone (7.1-->44.8 mIU/ml), and a human menopause gonadotropin test yielded no estradiol response (13-->11 pg/ml). The results suggest that primary ovarian failure in type I BPES can take place in early childhood.