Minimal mesangial lupus nephritis: a systematic review

OBJECTIVES

To summarize the clinical presentation, histological features, treatment, and outcome of minimal change nephropathy (MCN) in patients with systemic lupus erythematosus (SLE).

METHODS

We performed a systematic review of cases of MCN in SLE patients reported in the English literature from January 1985 to May 2009 by a Medline search.

RESULTS

The estimated prevalence of MCN in biopsy-proven lupus nephritis is 2.3% in childhood and 1.1% in adults. There are 13 individual cases (12 women, one man) of SLE-related MCN reported in the literature. The mean age of nephritis onset was 32.7 years. In six (46%) patients, MCN was the initial manifestation of SLE. All patients presented with nephrotic syndrome and two (15%) had active urinary sediments. Renal function was impaired in eight (62%) patients and six (46%) patients had active lupus serology. All patients responded promptly to high-dose glucocorticoids but four (31%) had relapse of proteinuria during their course of SLE. None of the patients developed thromboembolic or infective complications.

CONCLUSIONS

MCN is an uncommon histological class of lupus nephritis. Typically, patients present with heavy proteinuria, and transient renal dysfunction is common. The prognosis of MCN in SLE appears to be good because of its rapid response to glucocorticoids. Relapses of proteinuria may be reduced by the use of maintenance immunosuppression. Alkylating agents, calcineurin inhibitors, mycophenolate mofetil, and rituximab can be considered in glucocorticoid-dependent or refractory cases of SLE-related MCN.

Recombinant human arginase inhibits proliferation of human hepatocellular carcinoma by inducing cell cycle arrest

Human hepatocellular carcinoma (HCC) has an elevated requirement for arginine in vitro, and pegylated recombinant human arginase I (rhArg-PEG), an arginine-depleting enzyme, can inhibit the growth of arginine-dependent tumors. While supplementation of the culture medium with ornithine failed to rescue Hep3B cells from growth inhibition induced by rhArg-PEG, citrulline successfully restored cell growth. The data support the roles previously proposed for ornithine transcarbamylase (OTC) in the arginine auxotrophy and rhArg-PEG sensitivity of HCC cells. Expression profiling of argininosuccinate synthetase (ASS), argininosuccinate lyase (ASL) and OTC in 40 HCC tumor biopsy specimens predicted that 16 of the patients would be rhArg-sensitive, compared with 5 who would be sensitive to arginine deiminase (ADI), another arginine-depleting enzyme with anti-tumor activity. Furthermore, rhArg-PEG-mediated deprivation of arginine from the culture medium of different HCC cell lines produced cell cycle arrests at the G(2)/M or S phase, possibly mediated by transcriptional modulation of cyclins and/or cyclin dependent kinases (CDKs). Based on these results, together with further validation of the in vivo efficacy of rhArg-PEG against HCC, we propose that the application of rhArg-PEG alone or in combination with existing chemotherapeutic drugs may represent a specific and effective therapeutic strategy against HCC.

Acute renal failure associated with prolonged intake of slimming pills containing anthraquinones

Chinese herbal medicine preparations are widely available and often regarded by the public as natural and safe remedies for a variety of medical conditions. Nephropathy caused by Chinese herbs has previously been reported, usually involving the use of aristolochic acids. We report a 23-year-old woman who developed acute renal failure following prolonged use of a proprietary Chinese herbal slimming pill that contained anthraquinone derivatives, extracted from Rhizoma Rhei (rhubarb). The renal injury was probably aggravated by the concomitant intake of a non-steroidal anti-inflammatory drug, diclofenac. Renal pathology was that of hypocellular interstitial fibrosis. Spontaneous renal recovery occurred upon cessation of the slimming pills, but mild interstitial fibrosis and tubular atrophy was still evident histologically 4 months later. Although a causal relationship between the use of an anthraquinone-containing herbal agent and renal injury remains to be proven, phytotherapy-associated interstitial nephropathy should be considered in patients who present with unexplained renal failure.

Lack of neutrophil degranulation in low-dose endotoxin inhalation based on a novel intracellular assay

To study the nature of endotoxin or lipopolysaccharide (LPS) induced inflammation, we developed a method of quantifying intracellular human neutrophil elastase (HNE) in lysed sputum polymorphs as a means to study the degranulation status of LPS-recruited neutrophils. Induced sputum, blood and exhaled nitric oxide (NO) were collected from 10 healthy non-atopic human subjects after inhaling a single 15 microg dose of Escherichia coil LPS in an open study. At 6 hours, LPS inhalation caused significant increase of sputum and blood neutrophils but without parallel increase in myeloperoxidase, HNE or interleukin-8 (IL-8) in sputum sol and blood, or exhaled NO. Intracellular HNE in lysed sputum polymorphs or purified blood neutrophils did not show any significant changes between inhaled LPS and saline, nor was there any appreciable change in percentage HNE release induced by N-Formyl-Met-Leu-Phe (fMLP) in vitro. We concluded that in healthy humans, the transient neutrophilic inflammation induced by a single dose of inhaled 15 microg LPS is mainly characterized by cell recruitment, not enhanced secretion of granular mediators or increased exhaled NO based on our experimental conditions.

Remission of hepatocellular carcinoma with arginine depletion induced by systemic release of endogenous hepatic arginase due to transhepatic arterial embolisation, augmented by high-dose insulin: arginase as a potential drug candidate for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is auxotrophic for the semi-essential amino acid arginine, depletion of which leads to tumor death. In humans, arginine is not an essential amino acid since many adult somatic cells can re-synthesize it from other sources, such as citrulline. Enzymes capable of depleting arginine in vitro include the urea cycle enzyme arginase, which is found in abundance in human liver. For over three decades, arginase has not been considered as a potential drug candidate because of its low substrate affinity, short circulatory half-life and sub-optimal enzymatic activity at physiological pH, though its in vitro anti-tumor activities in certain tumors have been amply reported. Arginine deiminase, a bacterial enzyme from Mycoplasma hominus has been shown to induce HCC remission through the mechanism of arginine depletion. We report here an innovative treatment approach for the treatment of locally advanced and metastatic HCC with transhepatic arterial embolisation (TAE) of the liver tumor with lipiodol and gel foam as a means of inducing a leakage of hepatic arginase from the liver into the circulation. Hepatic arginase released into the systemic circulation rapidly depleted plasma arginine. High-dose insulin was included to induce a state of hypoaminoacidaemia to augment arginine depletion. With this protocol, we have treated seven patients with locally advanced and/or metastatic HCC. Five patients achieved arginine depletion, ranging from 0 to 20 microM (normal plasma level 100-120 microM); all had varying degrees of tumor remission in their primary tumors and extra-hepatic sites in the lymph nodes, lungs and bones, suggesting systemic anti-cancer effect of arginine depletion. The two non-responders did not show significant reduction in plasma arginine. Based on our findings, we propose that the urea cycle enzyme, arginase, is a good drug candidate for the treatment of HCC.

Effects of Fatty Acids on Growth and Poly-3-hydroxybutyrate Production in Bacteria

The effects of saturated and unsaturated fatty acids (lauric acid, palmitic acid, steric acid, oleic acid, linoleic acid, soybean oil) on Sphaerotilus natans, 0B17 (Pseudomonas sp.), and recombinant Escherichia coli DH5(/pUC19/CAB were studied. Oleic acid enhances Poly-3-hydroxybutyrate (PHB) production in these three bacterial strains, suggesting that the single double bond of the acid activates the polyhydroxylkanoate accumulation enzymatic reaction. Under the effect of lauric acid and linoleic acid, the growth of S. natans and 0B17 were totally inhibited. However, the enhanced PHB accumulation in recombinant E. coli was observed.

Microbial synthesis and characterization of physiochemical properties of polyhydroxyalkanoates (PHAs) produced by bacteria isolated from activated sludge obtained from the municipal wastewater works in Hong Kong

The first objective of this study was the measurement of physical properties of P(3HB-co-3HV) copolymers with different (hydroxybutyrate) HB to (hydroxyvalerate) HV ratios produced by Bacillus cereus (TRY2) isolated from activated sludge. The 3HV PHBV copolymers were 0.05, 22.6, 39.2, 54.1, and 69.1 mol%, respectively. The second objective was to study possible waste water treatment and production of PHAs at the same time by B. cereus (TRY2) and Pseudomonas spp. (TOB17) (both were isolated from activated sludge), recombinant Bacillus DH5alpha, and a combination of the above three bacteria. The results were satisfactory; the maximum COD and TOC of the sewage sludge reduced were 53.5% and 67.5%, respectively.

Thrombotic thrombocytopenic purpura as a rare complication in childhood systemic lupus erythematosus: case report and literature review

Thrombotic thrombocytopenic purpura is a rare but serious condition in childhood. It can be idiopathic or a complication of other diseases or drug therapy. We report on a 12-year-old Chinese girl who presented with fulminant systemic lupus erythematosus with progressive renal failure, pancytopenia, and cerebral dysfunction due to thrombotic thrombocytopenic purpura. The patient also had Pneumocystis carinii pneumonia, Pseudomonas septicaemia, and Herpes zoster infections as a result of immunosuppressive treatment. She responded to combined therapy with pulse methylprednisolone, cyclophosphamide, plasmapheresis, and intensive care support, and completely recovered renal and neurological function. A review of the English-language medical literature since 1968 identified 20 other paediatric cases of systemic lupus erythematosus and thrombotic thrombocytopenic purpura. Clinical features, treatment, and outcome of these cases are presented and discussed. Early recognition is important, and although plasmapheresis is not of proven benefit in severe cases of systemic lupus erythematosus, it is life-saving in lupus-related thrombotic thrombocytopenic purpura and must be instituted early to avoid a poor outcome.

Ni2+ removal and recovery from electroplating effluent by Pseudomonas putida 5-x cell biomass

Ni2+ and Cu2+ are the major heavy metal ions in electroplating wastewater of Hong Kong. In the present study, Pseudomonas putida 5-x cell biomass was used to remove Ni2+ from electroplating effluent. Ni2+ adsorption capacity of P. putida 5-x cell biomass cultured in sulphate-limiting medium was found to be minimum in early logarithmic growth phase, and maximum of 28.1 mg g(-1) in late stationary growth phase. Pretreated cells by 0.1 mol L(-1) HCl could greatly enhance the Ni2+ adsorption capacity of cell biomass from 28.1 to 36.7 mg g(-1) and had no significant effect on biomass loss. The adsorption process of P. putida 5-x fresh cells and pretreated cell all could be expressed with Freundlich isotherm. TEM analyses indicated that acidic pretreatment degraded the superficial layer-capsule outside of the fresh cell to improve the adsorption capacity of cell to Ni2+. The Ni2+ bound by P. putida 5-x cell biomass could be efficiently recovered using 0.1 mol L(-1) HCl, and the cell biomass could be reused at least five cycles for Ni2+ removal and recovery with 93% above removal efficiency and 98% above recovery rate. Owing to the Cu2+ presented in electroplating wastewater inhibiting Ni2+ adsorption process by P. putida 5-x cell biomass, two-stage biosorption processes should be designed to remove and recover Cu2+ and Ni2+ sequentially from electroplating effluent.

Treatment of malignant bone tumours by extracorporeally irradiated autograft-prosthetic composite arthroplasty

Autogenous bone graft which has been either autoclaved or irradiated is commonly used in oriental countries as an alternative to allograft. We started to use the technique of extracorporeal irradiation of the resected specimen and reimplantation (ECIR) in 1991. There was, however, a high incidence of fracture of the irradiated bone and loss of articular cartilage. In an attempt to reduce these complications, we combined the irradiated autograft with a conventional arthroplasty. Between 1995 and 1998, 14 patients underwent limb salvage by this method. Seven had an osteosarcoma, two bony metastases, three a chondrosarcoma, one a malignant fibrous histiocytoma, and one a leiomyosarcoma. Ten tumours were located in the proximal femur, two in the proximal humerus, and two in the distal femur.

One patient who had a solitary metastasis in the proximal part of the left femur died from lung metastases 13 months after operation. The remaining 13 patients were alive and without evidence of local recurrence or distant metastases at a mean follow-up of 43 months (28 to 72). Postoperative palsy of the sciatic nerve occurred in one patient, but no complications such as wound infection, fracture, or nonunion were seen. All host-irradiated bone junctions healed uneventfully within eight months. Using the Enneking functional evaluation system, the mean postoperative score for all 14 patients was 80% (57 to 93).

The use of irradiated autograft prosthesis composites reduces the complications of ECIR and gives good functional results. It may be a good alternative in limb-salvage surgery, especially in countries where it is difficult to obtain allografts.

Treatment of malignant bone tumours by extracorporeally irradiated autograft-prosthetic composite arthroplasty

Autogenous bone graft which has been either autoclaved or irradiated is commonly used in oriental countries as an alternative to allograft. We started to use the technique of extracorporeal irradiation of the resected specimen and reimplantation (ECIR) in 1991. There was, however, a high incidence of fracture of the irradiated bone and loss of articular cartilage. In an attempt to reduce these complications, we combined the irradiated autograft with a conventional arthroplasty. Between 1995 and 1998, 14 patients underwent limb salvage by this method. Seven had an osteosarcoma, two bony metastases, three a chondrosarcoma, one a malignant fibrous histiocytoma, and one a leiomyosarcoma. Ten tumours were located in the proximal femur, two in the proximal humerus, and two in the distal femur. One patient who had a solitary metastasis in the proximal part of the left femur died from lung metastases 13 months after operation. The remaining 13 patients were alive and without evidence of local recurrence or distant metastases at a mean follow-up of 43 months (28 to 72). Postoperative palsy of the sciatic nerve occurred in one patient, but no complications such as wound infection, fracture, or nonunion were seen. All host-irradiated bone junctions healed uneventfully within eight months. Using the Enneking functional evaluation system, the mean postoperative score for all 14 patients was 80% (57 to 93). The use of irradiated autograft prosthesis composites reduces the complications of ECIR and gives good functional results. It may be a good alternative in limb-salvage surgery, especially in countries where it is difficult to obtain allografts.

Avascular necrosis of femoral head after gamma-nailing for unstable intertrochanteric fractures

We reported on 7 cases of avascular necrosis of the femoral head after treatment of an unstable intertrochanteric fracture with the Asian Pacific gamma-nail. The incidence was about 1.16% (7 of 604) in our series. Good reduction and good implant position were achieved in all 7 men. Avascular necrosis was found about 6 months to 3 years after the initial operation, and all the fractures were solidly united at the final diagnosis. The possible etiologies were initial high energy trauma and combining basal neck fracture and iatrogenic damage of the blood supply to the femoral head.

Stress analysis of the disc adjacent to interbody fusion in lumbar spine

After anterior interbody fusion in the lumbar spine, the accelerated degeneration of the disc adjacent to the fusion levels was clinically observed. To understand the stress distribution of the adjacent disc, this study created a finite element model of the lumbar spine from L1-L5 vertebral body. The fusion model modified from the intact model was used to simulate the anterior interbody fusion. Various loading conditions, which included flexion, extension, lateral bending, and torsion, were applied to the finite element model to study the corresponding stress distribution. From the finite element model calculation, at a lower fusion site or more fusion levels, the stress of the disc adjacent to interbody fusion increased more than upper fusion site or single fusion level under flexion, torsion and lateral bending. Larger stress increase was estimated at the upper disc adjacent to interbody fusion than the lower disc adjacent to interbody fusion. In stress distribution, the upper disc adjacent to interbody fusion had a little alteration under torsion.

Intertrochanteric fractures in adults younger than 40 years of age

This study reviewed 66 intertrochanteric fractures in patients younger than 40 years old (average 33.0 years old; range 17-40 years old). In contrast to the usual population with intertrochanteric fractures, the factors male predominance (46/66), less pre-injury comorbidity (9/66), more outdoor high energy trauma (47/66), and more associated injuries (32/66) were evident. The distribution of associated injuries was wide. Some of them were life threatening. According to Boyd's classification, 20 were type I, 24 were type II, 13 were type III, and 9 were type IV. Twenty-nine were stable, and 37 were unstable. Stratified by the mechanism of injury, the difference in distribution between the subgroups was significant (p = 0.027, two-tail Fisher's exact test). Simple falls only caused Boyd type I and II fractures. Boyd type III or IV fractures were found more often after vehicular trauma or falls from a height. All the intertrochanteric fractures healed on average 70.5 days (range 31-213 days) after operation. The fractures resulting from vehicular trauma or fall from a height healed significantly more slowly (p = 0.02, univariant log-rank test). There were 6 intertrochanteric fracture-related complications. The mechanism of injury determines the character of intertrochanteric fractures in young adults. Given tougher bone stock, better healing ability, and less co-morbidity, proper management can lead to healing of all intertrochanteric fractures. The extent of functional recovery was also determined by the associated injuries.

Cefuroxime-impregnated cement at primary total knee arthroplasty in diabetes mellitus. A prospective, randomised study

We have performed a prospective single-blinded randomised study to evaluate the role of antibiotic-impregnated cement in the prevention of deep infection at primary total knee arthroplasty (TKA) in patients with diabetes mellitus. We studied prospectively 78 arthroplasties performed for osteoarthritis in such patients. They were randomly separated into two groups. In group 1 (41 knees), cefuroxime-impregnated cement was used while in group 2 (37 knees) cefuroxime was not added to the cement. The preoperative, intraoperative and postoperative management was the same for both groups. The mean follow-up was 50 months (26 to 88). There were no cases of deep infection in group 1, but five (13.5%) occurred in group 2 (p = 0.021). We conclude that cefuroxime-impregnated cement is effective in the prevention of deep infection at primary TKA in patients with diabetes mellitus.

Cerclage wiring in displaced both-column fractures of the acetabulum

We evaluated the effect of cerclage wiring in the open reduction and internal fixation of displaced both-column fractures of the acetabulum. This was a prospective clinical evaluation of such cases where the main surgical strategy was open reduction and internal fixation with cerclage wire and supplemental reconstruction plates. Data on 35 cases treated by open reduction (all via the triradiate approach)/internal fixations with cerclage wire and reconstruction plates were collected. The follow-up period was 40 months (18-69). Reduction with a fracture gap of less than 2 mm without articular stepping was achieved in all 35 cases. Postoperative complications developed in seven cases, including subcutaneous haematoma in two, wound infection in two and heterotopic ossification in three. All the complications had no adverse effect on the clinical outcome, and all the cases had good to excellent final results. Cerclage wiring is very useful and effective in the reduction and fixation of displaced both-column fractures of the acetabulum, and supplemental fixation with reconstruction plates and screws is necessary.

DSPP mutation in dentinogenesis imperfecta Shields type II

We identified a nonsense mutation (Gln45stop) in exon 3 of the dentin sialophosphoprotein (DSPP) gene in a Chinese family with dentinogenesis imperfecta Shields type II (DGI-II), in which the affected members showed discoloration and severe attrition of their teeth, with obliterated pulp chambers.

The influence of inserting a Fuji pressure sensitive film between the tibiofemoral joint of knee prosthesis on actual contact characteristics

OBJECTIVE

To investigate the influence of inserting a Fuji pressure sensitive film between the tibiofemoral joint of knee prosthesis on actual contact characteristics.

DESIGN

A finite element analysis was used to investigate the alteration of contact characteristics of the tibiofemoral joint due to inserting a pressure sensitive film between the contacting surfaces.

BACKGROUND

The discrepancy between actual contact behaviors of tibiofemoral joint of knee prosthesis and the measurement using Fuji pressure sensitive film was not discussed extensively. The change of direct contact circumstance of the tibiofemoral joint due to inserting a pressure sensitive film was not well reported.

METHOD

A two-dimensional finite element model of the tibiofemoral joint of knee prosthesis in the sagittal plane was constructed. Four different radii of the femoral component were used to investigate the conformity effect. Two-layers of plane strain element were used to model the pressure sensitive film. The influence of inserting a pressure sensitive film on the actual contact characteristics was analyzed by comparing the results of the change in contact radius.

RESULTS

Inserting a pressure sensitive film between contacting surfaces would disturb the original contact behaviors, especially in the lowest conformity design. The maximum difference of contact radius between the model simulating actual contact circumstance and the model with inserting a pressure sensitive film between contacting surface was 77% in the lowest conformity condition at the smallest load.

CONCLUSIONS

This study proposes a quantitative analysis of contact characteristics in the tibiofemoral joint of knee prosthesis between the models with and without inserting a pressure sensitive film into the contact surface. The measurement of contact area in artificial tibiofemoral joints by using Fuji pressure sensitive film is always overestimated its true contact area by 14-77%.

RELEVANCE

This study revealed the measurement of contact characteristics of artificial tibiofemoral joints by using Fuji pressure sensitive film which depends on not only the applied load, but also the conformity and material properties of the contact surface. Therefore, the information of the conformity and material properties of the contact surface should be provided as well as the applied load wherever a measurement of contact characteristics using Fuji pressure sensitive film is analyzed and interpreted.

Treatment of acute closed humeral shaft fractures with Ender nails

The effect of semirigid Ender nails (EN) in the treatment of closed humeral shaft fractures was reviewed and analyzed. Clinical study was set retrospectively with detailed parameters. One hundred and eighteen closed humeral shaft fractures, treated with closed reduction and internal fixation with ENs, were collected. The follow-up period was 78 (24-175) months. The average operation blood loss was 105 cc, operation time was 57 min, hospital stay was 6.5 days, and union time was 10.5 weeks. The postoperative complications included three superficial infections, one iatrogenic radial nerve palsy, eight nail backouts, and eight nonunions. In our experience, for closed humeral shaft fractures fixed surgically, EN is a good choice for its simplicity and efficacy, but the fracture gap should be minimized after fixation and postoperative care should be closely observed.

A novel magnetite-immobilized cell process for heavy metal removal from industrial effluent

The sorption and desorption of copper (II) (Cu[II]) ions from the wastewater by magnetite-immobilized cells of Pseudomonas putida 5-x with acidic pretreatment were studied. Pretreating cells with 0.6 N HCl was found to enhance greatly the adsorption capacity of biomass up to 85.6 mg/g and had no significant effect on the loss of P. putida 5-x cells during biosorbent pretreatment. The biosorption capacity to Cu2+ of magnetite-immobilized cells of P. putida 5-x harvested during various growth phases was also investigated. The experimental results illustrated that the adsorption capacity to Cu2+ of P. putida 5-x cultured in sulfate-limiting medium reached maximum during the late stationary growth phase or early death phase, and reached minimum during the log growth phase. The mechanism of copper sequestering by this type of biomass was studied via transmission electron microscopy. A degradation of the peptidoglycan layer of the cell wall was observed in the acidic pretreatment, but no further degradation appeared after the adsorption-desorption cycle. Cu(II) accumulated mostly on the surface of the cell walls and was effectively desorbed by the acidic treatment during the desorption process.

Surgical treatment for peroneal nerve palsy

BACKGROUND

Peroneal nerve palsy is the most frequently encountered mononeuropathy of the lower extremities. Although many studies advocated spontaneous resolution of peroneal nerve palsy, more recent studies confirmed obvious improvement with surgical treatment techniques.

METHODS

This study reviewed the results obtained from surgically treated peroneal nerve palsy in 14 patients who were admitted to our hospital between 1990 and 1996. The patients consisted of 12 males and two females with an average age of 31 years (range, 12-68 years). Peroneal nerve palsy in these patients was caused by direct or indirect injury, as confirmed by clinical examination and electromyography. The status of the nerve was observed for at least 4 months and explored when the nerve failed to reveal evidence of recovery. The nerve was decompressed, repaired or reconstructed by nerve grafting, according to the status of the injury. Weber scales were used to assess the peripheral neuropathies preoperatively and postoperatively.

RESULTS

At a mean of 23 months (range, 11-61 months), nerve palsy scores improved from an average of 5 points to 3.14 points. Despite the small number of patients, our results indicated that the time interval between onset of injury and date of surgical treatment (p < 0.05) was the most significant factor to influence the prognosis of surgery. Results obtained from surgery were not related to the method of treatment, length of nerve graft or mechanism of injury.

CONCLUSIONS

Because peroneal nerve palsy does not always resolve spontaneously, this study favored early surgical exploration for peroneal nerve dysfunction, based on at least 4 months of follow-up.

Surgical treatment of full thickness rotator cuff tear in patients younger than 40 years

BACKGROUND

Full thickness tear of the rotator cuff is a well-known entity in the middle-aged and elderly population and the results of surgical repair are well documented. Rotator cuff tear in patients under the age of 40 years is unusual and the cause and treatment are not well established. The present study reports 12 young patients with full thickness tear of the rotator cuff treated surgically.

METHODS

Open anteroinferior acromioplasty and cuff repairs were performed on every patient after failure of nonsurgical treatment. The average follow-up was 59.5 months (range, 36-100 months).

RESULTS

The average patient age at the time of surgery was 30.2 years (range, 17-39 years). Symptoms included pain and dysfunction in all patients and weakness in eight patients. The duration of symptoms before surgery ranged from 6 to 60 months (average, 22.8 months). Ten patients were able to return to their preinjury status within an average of 4.5 months (range, 3-9 months) after surgery. Three athletes were able to return to previous levels of competition. Nine patients had excellent functional results with regard to pain, motion, strength, function and satisfaction. Eleven patients were satisfied with the operation and had significant pain reduction compared with their preoperative status.

CONCLUSIONS

An acute traumatic event was the etiology of the rotator cuff tears in this study. The results of surgical treatment in this younger group of patients were satisfactory and were comparable to the outcomes reported for surgical treatment of rotator cuff tears in older patients and athletes.

Treatment of acetabular fractures: 10-year experience

BACKGROUND

Acetabular fracture is a controversial and difficult fracture to manage. We retrospectively evaluated the outcome of the traditional management of acetabular fractures.

METHODS

From 1987 to 1996, 112 cases of acetabular fracture presented at the Taipei Veterans General Hospital and were managed surgically in 73 cases and nonsurgically in 39 cases. The follow-up period was 90 (36-140) months.

RESULTS

In the nonsurgically managed group, congruent reduction was achieved in 29 cases (74.3%) and good to excellent functional results were achieved in 25 cases (64.1%). In the surgically managed group, congruent reduction was achieved in 60 cases (82.2%) and good to excellent functional results were achieved in 57 cases (74.3%). In 51 (45.5%) cases, early or late complications developed after management, including one femoral artery perforation, one screw penetration, three wound infections, one iatrogenic sciatic nerve injury, one deep vein thrombosis, 21 heterotopic ossifications, two chondrolyses, three avascular necroses of the femoral head and 18 cases of symptomatic traumatic arthritis.

CONCLUSIONS

The functional results correlated well with the final congruity of the joints and the severity of the complications.

Surgical treatment of displaced acetabular fractures - 72 cases followed for 10 (6-14) years

Seventy-two displaced acetabular fractures managed surgically were evaluated retrospectively. The follow-up period was 10 (6-14) yr. The commonest fractures were posterior wall (28) and both columns (10). The surgical approaches were Kocher-Langenbeck (47), ilioinguinal (19) and extended iliofemoral (6). No neural monitoring was used in operations and no preventive agents for heterotopic ossification or thromboembolism were used perioperatively. Reduction was rated congruent in 59 (81.9%) and noncongruent in 13 (18.1%). The early postoperative complications were 1 vascular injury, 1 iatrogenic sciatic nerve injury, 1 deep vein thrombosis and 2 wound infections. The late complications were heterotopic ossification in 20 patients, avascular necrosis of the femoral head in 4 and symptomatic arthritis in 10. Functional outcomes were rated as excellent in 31, good in 23, fair in 7 and poor in 11. Our results show that traditional management is effective enough for displaced acetabular fractures.

Ipsilateral hip and distal femoral fractures

We tried to find the trauma mechanism and treatment rationale of ipsilateral concomitant hip and distal femoral fractures involving the articular surface. Between 1988 and 1995, 15 cases of ipsilateral hip (confined to neck or trochanteric areas of the femur) and distal (confined to supra- and intercondylar area of the femur) femoral articular fractures were collected. The hip fractures consisted of 10 trochanteric fractures and five neck fractures, which were managed with reduction and fixation in 14 (Knowles' pin in eight, DHS in four and standard Gamma nail in two), and primary bipolar hemiarthroplastry in one. The distal femoral articular fractures were open in 11; these were managed with radical debridement, implantation of Septopal chains and immediate internal fixation, followed by prophylactic autogenous bone grafting 6 weeks later in the recent six cases (five Judet plates, four dynamic condylar screws and two condylar plates). The other four closed distal femoral fractures were managed with early reduction and internal fixation (two Judet plate, one dynamic condylar screw and one condylar plate). The union time was 20.3 (12-48) weeks for proximal fractures and 23.7 (12-36) weeks for distal fractures. Early infection developed in three cases. Nonunion of a femoral neck fracture developed in one case. The other complications were implant failure in one, coxa vara in one, refracture in one, delayed union in one and knee stiffness in one.

The effect of posterior capsulorrhaphy in primary total hip arthroplasty: a prospective randomized study

Between 1994 and 1997, 180 cases of primary total hip arthroplasty (THA) were performed with the posterior (Moore) approach for a variety of indications and studies prospectively. The cases were separated randomly into 2 groups to evaluate the effect of posterior capsulorrhaphy in the prevention of postoperative dislocation. In group 1 (96 cases), closure of the arthroplasty was performed with a posterior capsulorrhaphy; in group 2 (84 cases), closure was performed without capsulorrhaphy. The follow-up period was 38 months (range, 12-60 months). No dislocations occurred in group 1, whereas 2 dislocations (2.3%) occurred in group 2. Although the factors affecting dislocation in primary THA are many, a posterior capsulorrhaphy may be helpful in the prevention of posterior dislocation of primary THA performed with a posterior approach.

Construction of recombinant Escherichia coli strains for polyhydroxybutyrate production using soy waste as nutrient

Construction and comparison of recombinant Escherichia coli strains harboring the polyhydroxybutyrate (PHB) operon from Ralstonia eutropha using vectors possessing different promotors, as well as the production of PHB from soy waste by the recombinant strain, are reported. The lac promotor was the most efficient on expression of the phb operon among the three promotors studied: i.e., lac promotor, T7 promotor and the normal sigma 70 promotor. The pKS/PHB was the most efficient plasmid for phb operon expression among the three plasmids used: i.e., pKS-, pAED4, and pJM9131. It was observed that isopropyl-beta-D-thiogalactopyranoside was not required for the induction of the expression of phb operon. The cell dry wt and polyhydroxyalkanoate content by E. coli XL-1 Blue (pKS/PHB) were 3.025 g/L and 27.83%, respectively.

The influence of contact alignment of the tibiofemoral joint of the prostheses in in vitro biomechanical testing

OBJECTIVE

To investigate the influence of contact alignment of the tibiofemoral joint of the prostheses in in vitro biomechanical testing.

DESIGN

An experimental set-up was used to measure the total contact areas of the tibiofemoral joint of the prostheses subjected to a compressive load, and the malalignment situations were simulated.

BACKGROUND

The contact alignment of the femoral component related to the tibial component in the literature was not described clearly and the effect of malalignment on the testing method has not been reported well.

METHODS

Three commercial knee prostheses (Omnifit, Genesis, and AMK) were used for testing under a compression load (3000 N) at flexion 0 degrees and 10 degrees. After aligning the normal contact alignment, the simulated malalignment was done to evaluate the influence on the total contact areas in these conditions relative to the normal contact alignment. The simulated malalignment includes the medial-lateral translation (0.5 and 1 mm), anterior-posterior translation (2 and 4 mm) and internal-external rotation (1 degrees, 3 degrees and 5 degrees ) of the femoral component relative to the tibial component.

RESULTS

The ratios of total contact areas of malalignment relative to normal contact alignment ranged from 1.06 to 0.93 in medial-lateral malalignment in these three prostheses. In anterior-posterior malalignment, the ratios ranged from 0.69 to 0.79 in Omnifit, 0.93-0. 96 in Genesis and 0.96-1.04 in AMK. In internal-external malrotation, the ratios ranged from 0.90 to 1.03 in these prostheses.

CONCLUSIONS

This study proposes that contact alignment would affect the contact characteristics, especially in anterior-posterior alignment when high conformity knee prosthesis is tested. The contact alignment must be standardized in the procedure in in vitro biomechanical testing, which will be more objective to evaluate the contact characteristics of different knee prostheses.

RELEVANCE

This study revealed the importance of contact alignment of the tibiofemoral joint of the prosthesis in in vitro biomechanical testing. Many published reports of the biomechanical evaluations on different designs of knee prostheses would show different results due to contact alignment. Furthermore, this study indicates that the ideal contact characteristics of the tibiofemoral joint in original design will be changed when the prosthesis under the malalignment condition which was caused by surgery technique or soft tissues imbalance.

An in vitro comparison of the motion behavior of different bipolar endoprostheses

The relative motion of 3 different bipolar endoprostheses was evaluated in vitro. A paired fresh acetabulum was frozen at 0 degrees C and defrosted 12 hours before the experiment. Three bipolar endoprostheses were evaluated: UNIQHIP system (United Orthopedics), UHR system (Osteonics), and AML system (Depuy). The surface roughness and spherical roundness of outer shells and inner heads of the bipolar prostheses were measured before the experiments. The acetabulum and outer shell of the bipolar prostheses were fixed on a Bionix 858 material testing system axially by separate fixation tools. The axial load of 1,400 N and 2,800 N was than applied on the specimen. The axis was rotated from 0 degrees to 90 degrees at the speed of 1 degree/s. All 3 outer shells were tested to this paired acetabulum randomly and separately. The frictional torque on the outer bearing surface of the different prostheses was recorded by the material testing system. The frictional torque on the inner bearing surface was also measured by the same procedure as was done for the outer bearing. The final results were statistically compared by the 1-way analysis of variance test method. Bipolar prostheses of the UHR system showed the largest frictional torque on outer bearing when it was loaded with 1,400 N and 2,800 N. The final results showed that all the bipolar prostheses had ideal motion behavior when functioning under the loading of 1,400 N. The frictional torque on the inner bearing was found to be larger than the frictional torque on the outer bearing in some prostheses when the loading was increased to 2,800 N. Thus, the bipolar endoprostheses functioned as unipolar prostheses. The only relative motion remained between the outer bearing surface and the acetabulum. This effect causes complications, such as implant protrusion in the acetabulum.

AO fixateur interne in treating burst fractures of the thoracolumbar spine

BACKGROUND

A burst fracture of the thoracolumbar junction is an unstable spinal fracture, which is caused by high-energy trauma. There are many methods of treatment, both surgical and nonsurgical, in dealing with spinal burst fractures. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) Fixateur Interne (FI) system was introduced in 1985 for posterior spine surgery with a transpedicular screw system.

METHODS

From April, 1989, through December, 1994, we encountered 42 patients with 42 acute burst fractures of the spine; 26 were male and 16 were female, with an average age of 41.2 years. One fracture occurred on T11, seven on T12, 16 on L1, 11 on L2, one on L3, four on L4 and two on L5. According to the Denis classification, there were eight type A, 23 type B, five type C, three type D and three type E fractures. All of these patients received posterior reduction without decompression, posterior short segmental fixation with AO FI instrumentation and posterior fusion.

RESULTS

After follow-up for an average of 66.1 months, all fractures were found to have united with residual back pain in only six patients; five patients, including one with nonunion, had back pain without the necessity of medication, and the other one had occasional back pain that was well controlled by medication. The immediate postoperative Cobb's angle improved by an average of 14.2 degrees, and there was an average loss of 3.3 degrees at final follow-up. All patients were neurologically intact at final follow-up except two patients, who were Frankel D. Seven patients had complications during follow-up; one experienced nonunion; four experienced screw breakage, one had screw pullout, and the other experienced breakage of the connecting rod.

CONCLUSIONS

From our retrospective study, the outcome of burst fracture of the spine treated with AO FI instrumentation system was satisfactory.

Treatment of large skeletal defects in the lower extremities using double-strut, free vascularized fibular bone grafting

This article reports on the use of double-strut, free vascularized fibular grafts to treat six patients with infected nonunion or traumatic bone loss in the femur or tibia after prolonged treatment and multiple operations. The defects were 6-13 cm long. Five patients achieved solid union within 6 months, and one patient required additional cancellous grafting to achieve union at the distal end of the fibula. One patient experienced a stress fracture due to strenuous exercise, and union was achieved 3 months after reapplying an external fixator. Although three patients had some restricted knee motion, all patients had a satisfactory outcome in regard to walking, and no limb-length discrepancies were noted in any patient.

Salmonella infection in total hip replacement--report of successful reimplantation and review of the literature

A case of Salmonella enteritidis group C infection following total hip replacement was treated by resectional arthroplasty and appropriate antibiotics. Total hip replacement with reimplantation of an antibiotic-impregnated cemented hip prosthesis was performed five months later. The postoperative course was smooth and hip function was good, without any sign of infection recurrence throughout 10 years of follow-up. The treatment protocol and clinical results are discussed along with a review of the literature.

Vascularized iliac bone graft for displaced femoral neck fractures in young adults

From November 1989 to September 1994, a total of 26 patients (18 men and 8 women) with acute displaced femoral neck fractures were treated with closed reduction and Knowles pinning combined with vascularized iliac bone grafting. Mean patient age was 37.5 years (range: 24-48 years). The mean time interval from injury to surgery was 3.6 days (range: 1-10 days). One patient experienced loss of the reduction at 6 weeks postoperatively and subsequently went on to hip replacement. Mean follow-up for the remaining 25 patients was 56.2 months (range: 20-78 months). All fractures united within 4 months. The average union time was 3.3 months. Plain radiographs confirmed the presence of avascular necrosis in 2 patients during the final follow-up; 1 of these patients developed systemic lupus erythematous 1 year after the fracture and had been treated with high doses of corticosteroid. Functional and radiographic results were satisfactory in the remaining patients.

Tuberculous osteomyelitis in young children

Twenty-three cases of tuberculous osteomyelitis in children were reviewed. Age at diagnosis ranged from 10 months to 11 years; 17 patients were younger than 3 years. At clinical presentation, patients were generally afebrile with local swelling and painful limb disability. Delay in diagnosis was common, with an average of 4.3 months. Laboratory data showed mild increase in white cell counts and erythrocyte sedimentation rates. However, C-reactive protein levels were all within normal limits except one. Roentgenograms demonstrated osteolytic lesions over metaphyseal areas with surrounding soft-tissue swelling. All patients had received BCG vaccinations at infancy. None of the patients had pulmonary tuberculosis. No familial or environmental history could be attributed to these victims, nor was any immunodeficient disease noted. Bacille Calmette-Guérin (BCG) vaccination was suspected to be the cause of tuberculosis in these young children. All patients received surgical debridement and oral antituberculosis chemotherapy for 1 year. After an average follow-up period of 71.4 months, all children had complete bony healing and excellent clinical results.

[Linkage studies of a familial spastic paraplegia pedigree from Tibet]

OBJECTIVE

To study the location of disease-related gene in a hereditary spastic paraplegia family with autosomal dominant inheritance in Tibet.

METHODS

The AD-HSP family in Tibet was analyzed by linkage studies using 9 highly polymorphic microsatellite DNA markers at three chromosomal regions.

RESULTS

The maxium Lod- Score of D14S264 was 0.5163(theta=0.05); of D14S75, 2. 1072 (theta=0);+D14S69, 0.2840 (theta=0.10); of D14S266, 0.9311 (theta=0);of D14S66, 0.7991(theta=0);OF GABRB3, 0(theta =0.40);of D15S128, 0(theta=0.40); of D2S2255, 0 (theta=0.40);and of D2S2347,0(theta=0.40).

CONCLUSION

In this Tibetian family, the disease-related gene is linked to D14S75 locus of SPG3 region.

Percutaneous A1 pulley release for trigger digits

BACKGROUND

Recently, percutaneous trigger digit release has been reported as a safe, effective office procedure. The purpose of this study was to further assess the safety and efficacy of this technique.

METHODS

From November, 1996, to August, 1997, 69 consecutive patients with 71 primary trigger digits were treated with percutaneous A1 pulley release. The operations were performed using the tip of a 19-gauge needle, mounted on a 3-ml syringe. The mean age of the patients was 66 years. The mean duration of follow-up was 21 weeks. The patients were prospectively classified into two groups according to age, sex, digit involved, duration of symptoms and whether or not they had had previous local steroid injection.

RESULTS

Sixty-three digits were completely free of triggering. Residual triggering or inadequate release was found in eight digits at final follow-up. The success rate was not associated with sex, age, digit involved, duration of symptoms or history of local steroid injection. No major complications were found in this study, but minor complications included persistent local tenderness in nine digits and subcutaneous hematoma in six digits. Risk factors related to persistent local tenderness were female gender and trigger thumb.

CONCLUSIONS

Percutaneous A1 pulley release is an effective, safe and convenient procedure for the treatment of trigger digits.

Computerized tomography in the diagnosis of subluxation of the distal radioulnar joint

BACKGROUND

The diagnosis of distal radioulnar joint (DRUJ) subluxation is difficult. Routine radiographs are imprecise in clinical analysis. However, the anatomy and dynamic configuration of this articulation have been clearly defined utilizing computerized tomography (CT). Three CT criteria for the evaluation of DRUJ subluxation have been reported: Mino's criteria, the epicenter method and the congruity method. Previous reports discussed these criteria in the analysis of symptomatic DRUJ, but no clear conclusion has been reached. The purpose of this study is to investigate accurate criteria of CT in defining subluxation of the DRUJ.

METHODS

Eighty distal radioulnar joints in 40 patients with suspected DRUJ subluxation underwent CT scans of both symptomatic and asymptomatic wrists. The CT scan was obtained through the DRUJ with the forearm in neutral rotation, active full supination and active full pronation. Three CT criteria were used to assess the DRUJ in all positions of unstable and normal wrists.

RESULTS

Overall, 54 wrists were included in the final analysis. Seventeen symptomatic wrists had frank DRUJ instability diagnosed from true lateral radiographs, and 11 were reconfirmed from intraoperative pathology. The other 37 wrists had normal DRUJ. Among the three methods, the epicenter method had similar sensitivity to Mino's criteria and the congruity method. However, the epicenter method had much better specificity than Mino's criteria and the congruity method.

CONCLUSIONS

For accurate diagnosis of subluxation of the DRUJ, CT scan through the symptomatic DRUJ in neutral rotation, active full supination, active full pronation and analysis with the epicenter method are recommended.

Os supratrochlear dorsale of the elbow: a report of two cases

The os supratrochlear dorsale, an accessory ossicle of the elbow, has rarely been described in the literature. Rather than being caused by trauma, it is subject to trauma by elbow extension with secondary chondrometaplasia, resulting symptomatology. The aim of this report is to remind readers that its presence is crucial for both diagnostic and therapeutic purposes. Arthroscopic removal may be required to relieve persistent pain, catching and limited range of motion.

Acute closed humeral shaft fractures treated with dynamic compression plate

BACKGROUND

To define the efficacy of dynamic compression plates (DCPs) for the treatment of closed humeral shaft fractures.

METHODS

A total of 165 patients with closed humeral shaft fractures were studied retrospectively. There were 120 patients who underwent open reduction and internal fixation with DCPs and no bone grafting (BG). Forty-five patients received the same procedures with BG. The mean follow-up period was 93 months.

RESULTS

In the DCP without BG group, the average blood loss was 350 ml, operation time was 105 minutes, hospital stay was 8.5 days and fracture union time was 13.5 weeks. In the DCP with BG group, the average blood loss was 525 ml, operation time was 115 minutes, hospital stay was 7.9 days and fracture union time was 9.2 weeks.

CONCLUSIONS

In our experience, DCPs are effective for surgical fixation of humeral shaft fractures. Prophylactic BG is recommended for cases with more comminution.

Heterotopic ossification after cemented or uncemented bateman bipolar hemiarthroplasty

BACKGROUND

This is a retrospective study to evaluate the incidence of heterotopic ossification (HO) in cemented and uncemented femoral neck fractures treated with Bateman bipolar hemiarthroplasty.

METHODS

From October 1985 to July 1990, there were 451 cases of displaced intracapsular fractures of the femoral neck treated with Bateman bipolar hemiarthroplasty (261 uncemented vs 190 cemented) at the Veterans General Hospital-Taipei.

RESULTS

After an average follow-up of 46 months, there was more HO in the cemented group than in the uncemented group (p = 0.014, chi-squared test). The average surgical time was approximately 20 minutes longer and the average blood loss was approximately 160 ml more in the cemented Bateman bipolar hemiarthroplasty group.

CONCLUSIONS

HO formation is more common in cemented Bateman bipolar hemiarthroplasty than in the uncemented procedure. The incidence of HO is not related to age or sex.

Vascularized iliac bone graft for treating avascular necrosis of the femoral head

BACKGROUND

Nontraumatic avascular necrosis of the femoral head (ANFH) is a common disorder causing disability of the hip joint. The means for optimally treating this disease are still controversial. In this study we evaluated the relatively new technique of vascularized iliac bone grafting for treating ANFH.

METHODS

From March 1990 to March 1992, 17 hips (15 patients) with ANFH were treated using the vascularized iliac bone grafting technique in our hospital. The patients included 12 men and three women, with an average age of 38 years. Steinberg's classification was used to categorize the severity of hip disease. The clinical results were classified as excellent, good, fair and poor according to symptoms, hip function and roentgenographic changes after surgery. Life-table analysis was applied to assess graft survival and the log rank test was used to compare statistical differences between the steroid-related and nonsteroid-related groups.

RESULTS

Cumulatively, 16 hips (14 patients), excluding one patient (one hip) lost to follow-up, were clinically evaluated for an average of 68 months. Among 12 hips at Steinberg stage II, eight progressed to stage IV, three to stage III and only one remained at stage II. Although most hips at stage II showed mild to moderate disease progression on plain radiography, 58% of the hips (7/12) that progressed to less than IVb showed good to excellent results. In the three hips at stage III, one progressed to stage IVa and two to stage V. In the two hips at stage IV, one remained at stage IV at final follow-up and the other was lost to follow-up. The steroid-related and nonsteroid-related groups did not differ with respect to clinical results. Both groups had 63% (5/8) good to excellent results (p > 0.05, log rank test). Only four hips were converted to prosthetic arthroplasties at final follow-up. Overall, 63% (10/16) of the hips had good to excellent results, 12% had fair results and 25% had poor results. Graft survival after seven years of follow-up was 63%.

CONCLUSIONS

While treatment of ANFH still poses a challenge to orthopedic surgeons, the vascularized iliac bone grafting technique is a clinically acceptable option for treating the early stages of ANFH.

Closed humeral shaft fractures: a prospective evaluation of surgical treatment

OBJECTIVE

We tried to define the roles of the rigid dynamic compression plate (DCP) and the semi-rigid Ender nail (EN) in the treatment of closed humeral shaft fractures.

DESIGN

A prospective, randomized clinical study was performed with detailed comparison parameters.

MATERIALS AND METHODS

Ninety-one closed humeral shaft fractures were treated. Randomly, 30 humeri were treated with open reduction and internal fixation with DCP and no bone grafting (BG), 29 were treated with the same procedure but with BG, and 32 were treated with closed reduction and internal fixation with Ender nails. The average follow-up period was 32 months (range, 13-54 months).

MEASUREMENTS AND MAIN RESULTS

In the group with DCP without BG, the average blood loss was 270 mL, operation time was 92 minutes, hospital length of stay was 6.5 days, and union time was 12.5 weeks. In the group with DCP with BG, the average blood loss was 325 mL, operation time was 108 minutes, hospital length of stay was 6.9 days, and union time was 9.4 weeks. In the EN group, the average blood loss was 114 mL, operation time was 54 minutes, hospital length of stay was 5.6 days, and union time was 9.9 weeks. Analysis of variance and Fisher's exact test were used to evaluate the statistical significance.

CONCLUSION

In our experience, for humeral shaft fractures fixed surgically, EN is better than DCP without BG. When DCP is chosen for the means of fixation, prophylactic BG is recommended, especially in cases with more comminution.

Segmental tibial fractures treated with interlocking nails. A retrospective study of 33 cases

We treated 33 segmental tibial fractures with interlocking nails between 1986 and 1991. All fractures were managed with calcaneal traction, closed reduction, reaming and fixation with a Grosse-Kempf interlocking nail. The patients were followed for at least 15 months. The mean duration to union was 17 (12-20) weeks for the distal fractures and 20 (12-34) weeks for the proximal ones. There were only 3 cases of delayed union of the proximal fracture, 2 of which united after dynamization by removal of distal screws and 1 after autogenous bone grafting. There were 2 cases of deep infection, which were diagnosed after the fractures were united. The infection was treated with removal of the nail, reaming, and antibiotic treatment intravenously for 2 weeks and orally for 4 weeks. All patients returned to their previous activity level. We conclude that segmental tibial fractures can be treated with an interlocking nail and have a high rate of union and a low complication rate.

Another pedigree with pure autosomal dominant spastic paraplegia (AD-FSP) from Tibet mapping to 14q11.2-q24.3

The mutant in a family with autosomal-dominant spastic paresis in Northern Tibet was mapped by linkage analysis with several microsatellite markers to a gene locus at 14q11.2-q24.3, an area to which a few mutants leading to a condition with similar clinical signs have previously been mapped. The mutant observed in this pedigree probably arose de novo. Gene loci at 2p21-p24 and 15q, which have been found for other pedigrees with dominant spastic paresis, were excluded. The data in this pedigree do not contradict the hypothesis proposed by another group that there might be anticipation.

Core decompression in treating ischemic necrosis of the femoral head

BACKGROUND

The application of core decompression in the treatment of ischemic necrosis of femoral head (INFH) is to preserve the joint at early stage of the disease. Although excellent results have been obtained in many series, its effectiveness is questionable because of high rates of failure. This study is to evaluate the effectiveness of this technique in our patients with INFH receiving core decompression as the sole treatment.

METHODS

Although 91 patients were treated with core decompression in Veterans General Hospital-Taipei from 1980 to 1993, only 71 were considered as the valid cases after having been followed for 24 to 165 months (mean 56.7 months). Of 84 hips treated, 49 hips were steroid induced, 20 idiopathic, 14 alcohol related, and one related to trauma. Twenty-five hips were at Steinberg stage I, 32 at stage II, nine at stage III, 17 at stage IV, and one at stage VI.

RESULTS

The results were poor in 22 (26.19%) hips since the patients required hip prosthesis. Fair results were rated in 37 (44.05%) hips since progressive collapse occurred in the femoral head and the patients suffered from moderate hip pain. Good results were found in nine (10.71%) hips since the lesion showed no progression and the patients had only occasional pain. Excellent results were obtained in 16 (19.05%) hips since the patients had no pain and the lesion had no progressive change. The satisfactory rate in the nonsteroid-related hips (33% or 12/35) was significantly higher than in the steroid-related hips (27% or 13/49). The overall satisfactory result was only 30%.

CONCLUSIONS

Although core decompression may not be effective in preventing progression of INFH, it may relieve temporary pain and delays the need for hip arthroplasty in some patients.

One-stage reconstruction of skin defect and patellar tendon rupture after total knee arthroplasty. A new technique

A case is presented herein in which infected total knee arthroplasty associated with a skin defect and patellar tendon rupture was reconstructed with lateral gastrocnemius-Achilles tendon complex after infection was controlled. The results were satisfactory, and the technique proposed herein is highly promising for treating such complicated circumstances after total knee arthroplasty, as not reported previously.

Surgical treatment of seat belt type injury of the thoracolumbar spine

BACKGROUND

Seat belt type injury of thoracolumbar spine is an uncommon injury characterized by disruption of the posterior elements of the spine. The fracture has long been treated conservatively, but progressive kyphotic deformity developed frequently.

METHODS

From January, 1991 through December, 1992, 10 cases of seat belt type injury of the thoracolumbar spine were encountered at our hospital with an incidence of 8% in overall spinal fractures. Of these patients, eight patients were male and two were female, average age 30.7 years old. The causes included motor-vehicle accident in five patients, fall from height in four, and stricken by a falling electric pole in one. None of the victims of motor vehicle accidents wore seat belt. All of them received open reduction, posterior internal fixation and posterior fusion.

RESULTS

After follow-up for an average of 42.2 months, the average kyphotic angulation was 5.7 degrees. Back pain and function of these patients were all rated good. None of them suffered from neurologic deficit. One patient with breakage of transpedicular screws was encountered during follow-up, but there was no complaint.

CONCLUSIONS

In treating seat belt type injuries of spinal column, benefits of operation outweigh the risks. Besides, the clinical result is satisfactory and more aggressive surgical approach should be encouraged.