Double screw versus angular stable plate fixation of scaphoid waist nonunions in combination with intraoperative extracorporeal shockwave therapy (ESWT)

INTRODUCTION

Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT.

MATERIALS AND METHODS

Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41 mJ/mm² intraoperatively. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. To confirm union, a CT scan of the wrist was performed.

RESULTS

Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant. However, at a mean follow-up interval of 34 months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative.

CONCLUSIONS

Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.

Rehabilitation after distal radius fractures: is there a need for immobilization and physiotherapy?

Although the literature generally agrees that displaced distal radius fractures require surgery, no single consensus exists concerning the length of immobilization and type of post-operative physiotherapeutic rehabilitation program. Palmar locking plate fixation represents a very stable fixation of the distal radius, and was assessed biomechanically in various studies. Surprisingly, most authors report additional immobilization after plate fixation. One reason might be due to the pain caused during active wrist mobilization in the early post-operative stages or secondly to protect the osteosynthesis in the early healing stages preventing secondary loss of reduction. This article addresses the biomechanical principles, current available evidence for early mobilization/immobilization and impact of physiotherapy after operatively treated distal radius fractures.

Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy

INTRODUCTION

Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT.

MATERIALS AND METHODS

The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52 months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41 mJ/mm² within 2 weeks after surgery. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, Disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. In addition, each patient had a CT scan of the wrist.

RESULTS

A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O'Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used.

CONCLUSIONS

Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.

Early Passive Movement in flexor tendon injuries of the hand

INTRODUCTION

Flexor tendon injuries are underestimated considering their anatomical function in the hand. According to the publications of Kleinert, Verdan and Kessler, primary suturing of the flexor tendon combined with immediate postoperative physiotherapy in terms of "Early Passive Movement" became the standard form of therapy following acute flexor tendon injuries of the hand.

MATERIALS AND METHODS

In a study between 2007 and 2009, a total of 115 flexor tendon injuries were analysed retrospectively. All patients were treated using a two-strand repair technique according to Zechner. They received physiotherapy from the first postoperative day according to the Viennese flexor tendon rehabilitation protocol. For statistical purposes, the factors: age, gender, range of motion (ROM), follow up interval, affected flexor tendon and zone were analysed. The time between injury and surgery was also determined, classified into groups and included in the study. On the basis of the range of motion AROM, the Buck-Gramcko and modified Strickland Score was calculated.

RESULTS

The mean follow-up interval was 7 months. Using the Buck-Gramcko and Strickland Score an "excellent" overall result was achieved. Complications occurred in 3.5 %, one secondary rupture (0.9 %), two tendon adhaesions requiring tenolysis (1.7 %) and one case of infection (0.9 %). The time interval between injury and operation, gender, affected zone, flexor tendon and affected finger nerve had no influence on the Buck-Gramcko and Strickland Score.

CONCLUSIONS

Using Zechner's core suture technique as the primary treatment, combined with immediate postoperative physiotherapy in terms of "Early Passive Movement" according to the Viennese flexor tendon rehabilitation programme, an excellent clinical outcome and low complication rate was acchieved.

LEVEL OF EVIDENCE

IV: case series.

Serum and dietary vitamin D and cardiovascular disease risk in elderly men: a prospective cohort study

BACKGROUND AND AIM

Recent research suggests that low vitamin D may be associated with cardiovascular disease (CVD).

METHODS AND RESULTS

We prospectively evaluated the association of dietary plus supplemental vitamin D intake and serum 25(OH) vitamin D with CVD incidence in the Osteoporotic Fractures in Men (MrOS) Study. Vitamin D intake was measured using a food frequency questionnaire and self-reported supplemental intake in 3094 men (mean age 76.4 years). From a subset of this population, we measured 25(OH) vitamin D in 813 men. Median 25(OH) vitamin D was 25.3 ng/mL. During a median follow-up of 4.4 years, there were 472 CVD cases, including 371 from coronary heart disease (CHD) and 101 from cerebrovascular attack (CVA). In the 25(OH) vitamin D sub-cohort, there were 140 cases of CVD including 115 from CHD and 25 from CVA. We used a Cox proportional hazards regression to calculate hazard ratios (HR) for CVD by vitamin D quartile. After adjusting for age, season, and standard CVD risk factors, the lowest quartile of 25(OH) vitamin D (HR, 1.18; 95% CI, 0.69-2.03) and vitamin D intake (HR, 0.76; 95% CI, 0.56-1.04) were not significantly associated with CVD incidence, compared to the highest vitamin D quartiles. When 25(OH) vitamin D was further analyzed by sufficiency (≥30 ng/mL), insufficiency (≥15-29.9 ng/mL), and deficiency (<15 ng/mL), vitamin D deficiency was not significantly associated with CVD incidence compared to sufficiency (HR 1.34; 95% CI 0.65-2.77).

CONCLUSION

Vitamin D intake and serum 25(OH) vitamin D were not associated with CVD risk.

Ixabepilone, mitoxantrone, and prednisone in patients with metastatic castration-resistant prostate cancer refractory to docetaxel-based therapy: A phase II study of the DOD Prostate Cancer Clinical Trials Consortium

5058

Background: Mitoxantrone (M) plus prednisone (P) and ixabepilone (Ix) each have modest, non cross-resistant activity as second line chemotherapy regimens in docetaxel-refractory patients with CRPC. These agents were therefore combined in a phase I study which demonstrated anti-cancer activity and defined the recommended phase II dose used in this trial. Methods: Patients with metastatic CRPC and progression after 3 or more cycles of docetaxel were enrolled in a phase II multicenter study of the combination of prednisone 5 mg BID, Ix (35 mg/m2) and M (12 mg/m2) administered intravenously on day 1 every 21 days, with pegfilgrastim (6 mg on day 2) support. Results: To date, 43 pts have been enrolled and have received a median of 4 cycles. Of 37 patients currently evaluable for response, 14 (38%; 95% CI: 22–55%) have had a confirmed ≥50% decline in PSA and 19 (51%; 95% CI 34–68%) have had a confirmed ≥30% decline in PSA. Two of 15 patients with evaluable measurable disease (13%) have had a RECIST-defined objective response. All 43 patients are evaluable for toxicity. Grade 3 or 4 neutropenia was seen in 6 pts (17%) and grade 3 or 4 thrombocytopenia was seen in 3 (8%). Nonhematologic grade 3/4 events possibly related to study drug have included grade 3 fatigue (3 pts), grade 3 pneumonia (2 pts), and grade 3 atrial fibrillation, grade 4 myocardial infarction, grade 4 prostatitis, grade 3 nausea/vomiting, grade 3 neuropathy, grade 3 elevated transaminases, grade 3 dizziness, grade 3 dehydration, grade 3 shortness of breath, and grade 4 vasovagal syncope (1 pt each). Grade 2 neuropathy has been seen in 4 patients. Conclusions: The Ix, M, P regimen is active as second-line therapy in CRPC patients with progressive disease after docetaxel therapy and is reasonably well tolerated. Further investigation of this regimen is warranted. This study was supported in part by CTEP/NCI and the DOD Prostate Cancer Clinical Trials Consortium.

[Table: see text]

A phase II trial of high-dose calcitriol and docetaxel in patients with untreated, incurable pancreatic adenocarcinoma

15099

Background: Taxanes have activity in patients with advanced pancreatic adenocarcinoma. In preclinical studies, calcitriol, the active form of vitamin D, potentiates docetaxel-induced cell death in pancreatic and prostatic cancer cell lines. Clinically, single institution and randomized prostate cancer trials using weekly high-dose calcitriol with docetaxel have demonstrated high PSA response rates (J Clin Oncol 2003, 2007). Herein we report results from a phase II study of the identical regimen in patients with incurable pancreatic adenocarcinoma. Methods: Patients with a histologic diagnosis of locally advanced or metastatic pancreatic adenocarcinoma, Zubrod PS 0–2, and adequate organ function were eligible. Previous non-docetaxel adjuvant chemotherapy and radiation were permissible. Patients received calcitriol 0.5 mcg/kg orally day 1, followed by docetaxel 36 mg/m2 on day 2. Therapy was given weekly for 3 weeks, followed by a 1 week break, and patients were treated until progression. The primary endpoint was time-to-progression (TTP). Results: 24 patients with metastatic and 1 with locally advanced (25 total) were enrolled, treated and are evaluable for efficacy and toxicity. Median age and PS were 60 (range 30 to 79) and 1, respectively. 68% were males, and all were white. Three patients are alive and 22 have died. The median number of cycles was 1 (range 0 to 12). 3 patients (12%, 95% CI 3 to 31) achieved a partial response, and 7 (28%) stable disease for at least 7 weeks. Median TTP and median overall survival were 2.2 and 5 months respectively. Potentially treatment-related common grade 3/4 toxicities included: thrombosis -12%, abnormal LFTs-16%, nausea-8%, fatigue-16%, infection-12%, neutropenia/leucopenia-16%, effusion-8%, abnormal electrolytes-24%, and infusion reaction-4%. Conclusions: The combination of docetaxel and high-dose calcitriol has activity in pts with advanced pancreatic cancer, but the regimen offers no apparent advantage over historical results achieved with standard gemcitabine.

No significant financial relationships to disclose.

Tungsten particles mimicking the microcalcifications seen in ductal carcinoma in situ

Mammographic detection and characterization of breast microcalcifications is important in the early diagnosis of ductal carcinoma in situ. A case is presented where tungsten microparticles simulated microcalcifications and prompted a full diagnostic assessment. The likely origin of the particles is discussed and the published work on metallic particles in the breast is reviewed. Awareness of possible alternative causes for apparent microcalcifications at mammography is important for the breast radiologist and pathologist.

Acyclovir-induced colitis

Three patients developed acute colitis, either de novo, or as an exacerbation of pre-existing colitis, following the use of oral acyclovir, prescribed for Herpes zoster or Herpes simplex infection. Rechallenge with oral acyclovir was performed in one patient, and resulted in a recurrence of colitic symptoms. It is speculated that acyclovir can have a direct irritant effect on large bowel mucosa.

A simian varicella virus (SVV) homolog to varicella-zoster virus gene 21 is expressed in monkey ganglia latently infected with SVV

We have sequenced a simian varicella virus (SVV) open reading frame (ORF), 3,123 bp in length, whose product has 51% amino acid homology with the sequence encoded by the ORF of varicella-zoster virus gene 21. Several regions are highly conserved between the two ORFs, with homologies of approximately 80%. The SVV gene is transcribed in tissue culture cells productively infected with SVV and in monkey ganglia latently infected with SVV.

Configuration of latent varicella-zoster virus DNA

The configuration of latent varicella-zoster virus (VZV) DNA was analyzed by PCR. Template DNA for both internal and terminal VZV primers was present in a 1:1 ratio in ganglionic DNA, compared with a 15:1 ratio in DNA extracted from VZV virions, indicating that the VZV genomic termini are adjacent in latently infected human ganglia.

Comparison of values of antibody to Bordetella pertussis antigens in young German and American men

Pertussis is well controlled in the United States by routine childhood immunization. In contrast, this disease is endemic and epidemic in Germany because routine immunization has not been implemented. To gain information relating to the epidemiology of Bordetella pertussis infections, we examined the prevalence and magnitude of B. pertussis agglutinins and of IgG and IgA antibodies (detected by enzyme-linked immunosorbent assay) to four B. pertussis antigens--lymphocytosis-promoting factor, filamentous hemagglutinin, pertactin, and fimbriae-2--in the sera of 119 American university students and 119 German military recruits of similar age. Geometric mean titers of agglutinins and geometric mean values for IgG antibodies to the four antigens were two- to threefold higher in sera from the American students than in sera from German recruits. In contrast, the geometric mean IgA values and the percentage of subjects with detectable IgA antibodies to the four antigens were similar in the two populations. Since IgA antibody results mainly from infection and not from immunization, our data suggest that B. pertussis infections are common among both American and German young adults despite the marked difference in rates of clinical pertussis in the two countries.

Configuration and terminal sequences of the simian varicella virus genome

The simian varicella virus (SVV) genome is a linear DNA molecule consisting of a unique short (Us) and a unique long (UL) region. The Us is bounded by internal (IR) and terminal inverted repeats and inverts such that virion DNA contains equimolar amounts of two genome isomers. We have sequenced the right and leftward termini and the UL-IR junction region of the SVV genome. A sequence motif common to other herpesviruses, consisting of A and T residues surrounded by G+C-rich regions, was found near the rightward terminus of the SVV genome. Sequence analysis showed no repeats surrounding the UL region of the genome. Nucleic acid hybridization and polymerase chain reaction (PCR) amplification using primers from the right and leftward ends of the SVV genome indicated that the UL region inverts. PCR amplification also showed that, compared with virion DNA, SVV genomes with connected termini are increased in infected cell DNA, suggesting the presence of circular or concatemeric genomic molecules.

ON THE THEORY OF EXPLOSIVELY DISPERSED SEEDS: A CORRECTION

Attention is drawn to an error in two earlier papers on seed dispersal (Beer and Swaine, 1977; Swaine and Beer, 1977). The correction of the error leads to quantitative changes in the earlier results which do not substantially affect the biological conclusions drawn.