Demineralized bone bandeau in a patient with kleeblattschädel skull deformity.

Management of complex craniofacial deformities in the neonatal setting can pose daunting reconstructive challenges due to the limited supply of autogenous bone. We present a patient who was born with idiopathic nonsyndromal pansynostosis and the associated kleeblattschädel skull deformity. In this setting the patient's initial evaluation was suggestive of raised intracranial pressure and, as such, an emergent decompression was required. The native bone was unsuitable for reconstruction. Therefore, an allogenic demineralized perforated cortical iliac bone graft was used as the cornerstone of the reconstruction. Subsequent 2-year follow-up utilizing both clinical and microscopic evaluation revealed excellent osseous integration of the demineralized bone implant with near-total transformation into living bone. This clinical success has encouraged us to increase our utilization of this bone substitute in the neonatal setting.

Topical treatment of the aging face.

This article discusses the various over-the-counter and prescription products available to help improve sun-damaged skin, as well as superficial peeling agents. Practical suggestions for treating patients are given.

Long-term outcome of extensive skull reconstruction using demineralized perforated bone in Siamese twins joined at the skull vertex.

The successful use of cortical demineralized perforated bone in the treatment of extensive skeletal defects in children is exemplified by this case involving Siamese twins joined at the skull vertex. Four years following extensive skull reconstruction using demineralized perforated bone, an examination revealed successful calvarial reconstruction in one twin. The other twin required additional implants of demineralized perforated bone to fill in defects. However, a histologic examination taken following this additional procedure revealed that these implants neither caused tissue reaction over a 4-year period, nor showed signs of resorption. Bony remodeling and new bone formation were in progress. Compared with other bone substitutes, demineralized perforated bone has proven to be effective in the treatment of large skull defects in children.

Resurfacing with topical agents.

Evaluation of the aging face reveals many changes such as lentigines, coarseness, senile purpura, and fine lines that can be blamed primarily on photoaging. There are many topical preparations that are now being used or are under investigation for facial rejuvenation. These include retinold creams, alpha-hydroxy acids, Ethocyn (Chantal Skin Care Corp, Los Angeles, CA), topical vitamins, and topical hormonal treatments. There has been substantial media attention devoted to these "antiaging" cures but there is a lack of scientific evidence to support some of these claims. After review of these agents, a practical approach to the patient requesting younger-looking skin is presented.

Biologic remodeling after anterior cruciate ligament reconstruction using a collagen matrix derived from demineralized bone. An experimental study in the goat model.

A matrix of demineralized cortical bone was used to reconstruct the anterior cruciate ligament in the goat model. This graft underwent considerable site-specific remodeling and transformation from a Haversian system at time zero into a ligament-like structure at 1 year. This transformation included new bone formation filling the osseous tunnels and replacing the demineralized matrix, development of a ligament-like transition zone within the graft, and ligamentous collagen orientation with crimp in the intraarticular portion of the graft. One year after surgery, the mean anterior-posterior translation in the reconstructed stifle joints at 30 N of tibial loading was 2.1 +/- 0.4 (+/- SEM). The mean ultimate force to failure for the reconstructed ligament at 1 year was 474 +/- 146 N compared with the time-zero (initial) strength of the matrix of 73 +/- 9 N. The cellular repopulation of the graft had no associated inflammatory cells. The potential clinical significance of these findings includes 1) replacement of a collagen matrix with bone within the osseous tunnels, 2) establishment of a more physiologic fibrocartilage transition at the graft insertion site, 3) the time-zero structural properties of a collagen matrix increasing to more desired values with biologic remodeling, and 4) a sterile biologic allograft with essentially no long-term inflammatory response.

Cranioplasty in the growing canine skull using demineralized perforated bone.

This study was designed to test the hypothesis that demineralized perforated bone matrix implant from canine skull and tibia induces new bone formation within the calvarial defect comparable with the bone induced by autogenous graft. We also were interested in determining whether demineralized perforated bone matrix implants from membranous bone have greater osseoinductive capacity in the calvarial area than demineralized perforated bone matrix implants from endochondral bone. Forty 12-week-old purebred beagles were used. Group I consisted of animals with unrepaired surgically created calvarial defects healed by secondary intention (n = 10). Group II consisted of animals with surgically created calvarial defects in which the bone was removed and replaced with an autograft (n = 10). Group III consisted of animals with surgically created calvarial defects in which the bony defect was closed with a demineralized perforated bone matrix implant obtained from beagle calvaria (n = 10). Group IV consisted of animals with surgically created calvarial defects in which the bony defect was closed with a demineralized perforated bone matrix implant obtained from beagle tibia (n = 10). The two control groups (I and II) allowed us to isolate the inductive capacity of demineralized perforated bone matrix implants and compare it with the healing of the bone defects left unrepaired or repaired with calvarial autografts. Animals were sacrificed after 8 and 12 weeks. In the present study we were able to verify that demineralized perforated bone matrix implants are well accepted in the calvarial defects with little tissue reaction and remarkably little osteoclastic activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Craniofacial neurosurgical approach for extensive hyperostotic meningioma.

We present a patient with a craniofacial meningioma that had been considered inoperable for 8 years but has now been successfully treated using the combined neurosurgical and craniomaxillofacial approach. The tumor extensively involved the meninges, skull, face, left orbit, and maxilla. Vision and mild proptosis of the left eye had worsened over the last several years. Computed tomography and magnetic resonance imaging scans revealed an extensive intraosseous meningioma with intracranial and extracranial extension. An angiogram revealed an intensely vascularized mass supplied by a markedly enlarged ophthalmic artery. The tumor was approached through a bicoronal incision. The meningioma that extended into the dura was removed entirely from the brain. The left orbital roof and the lateral and medial walls were resected along with the meningioma, which extended through the orbit into the maxilla. The defect in the dura was closed with a pericranial flap. Split parietal bone and lyophilized cartilage were used for reconstruction of the cranial and orbital defects. Three and a half months after the initial surgery, further reconstruction was performed using calvarial, rib, and iliac bone and lyophilized cartilage. A methylmethacrylate implant was inserted but then removed due to chronic wound drainage. It was substituted with demineralized perforated bone implants from Pacific Coast Tissue Bank. Seventeen months after the initial surgery, there was no evidence of the tumor.

Biomechanical comparison of bone graft used in anterior spinal reconstruction. Freeze-dried demineralized femoral segments versus fresh fibular segments and tricortical iliac blocks in autopsy specimens.

This study compares the compression strength of frozen corticocancellous iliac blocks and short fibular segments with freeze-dried, partially ("surface") demineralized microperforated (FDPDM) short femoral segments. Three blocks from each iliac crest and segments from the fibular and femoral diaphyses were retrieved. The femoral segments were microperforated, demineralized for 24 hours, and freeze-dried. All were then loaded to failure in a stress testing machine. The FDPDM showed a significantly higher failure load and stiffness than the fibular segments and the iliac crest segments. The femoral and fibular segments were similar in strength but significantly higher than iliac crest grafts. Compared with commonly used frozen grafts, freeze-dried partially demineralized femoral segments may be used safely as axial load-bearing struts in anterior spine reconstruction.

Biomechanical assessment of surface demineralized micro-perforated femoral diaphyseal segmental allograft.

The use of surface demineralized micro-perforated femoral allograft (SDMFA), in the form of short diaphyseal segments, is of interest for anterior thoracic and lumbar spine reconstruction. Its reported osteoinductive capacity is enhanced by demineralization, though the mechanical strength is reduced. The strength of SDMFA segments was significantly higher at 24 h of demineralization time as compared to 48 h of demineralization time. The SDMFA segments from the junction of the proximal and mid-third of the femoral diaphysis had the greatest load to failure and stiffness.

Demineralized perforated bone implants in craniofacial surgery.

Between July 1990 and September 1991, demineralized perforated allogeneic bone implants (Pacific Coast Tissue Bank, Los Angeles, CA) were placed in 72 patients. Because many patients received more than one implant, a total of 248 implants were used in 80 procedures. The technology of processing demineralized bone implants is described in detail. All patients were operated on by one surgeon (K.E.S.) at the Humana Craniofacial Institute in Dallas, Texas. Forty-one patients had craniofacial deformities, 16 had secondary deformities following cleft lip and palate repair, 8 had bony defects following removal of tumors, and 10 had various skeletal deformities following trauma. Of the 72 patients, 6 had two surgical procedures during which additional implants were inserted. Implants placed in the cranial vault and the maxillary complex, including alveolar grafts, were inlay grafts, whereas implants placed in the orbital, nasal, paranasal, temporal, and malar areas were onlay grafts used for contouring, augmentation, or both. Complications were limited to delayed wound healing in 6 patients. According to our observations, demineralized perforated bone implants represent an encouraging alternative to autogenous bone grafting. Further clinical and experimental studies are necessary to obtain more information about this material.

Graft perforations favor osteoinduction. Studies of rabbit cortical grafts sterilized with ethylene oxide.

The healing of freeze-dried, ethylene oxide sterilized, segmental, allogenic cortical bone grafts was investigated in 15 rabbits using a 2-cm ulnar diaphyseal defect. Five different groups of bone grafts were evaluated: 1) unperforated undemineralized, 2) perforated undemineralized, 3) unperforated demineralized, 4) perforated demineralized, and 5) perforated demineralized grafts enclosed by silicone rubber (Silastic) sheets. There were 3 animals in each group. At 18 days, the study was terminated, and the implants were examined using radiographs and qualitative histologic preparations. We observed that healing of perforated demineralized bone was superior to unperforated demineralized bone, that undemineralized bone was partially sequestered in reactive lacunae, and that perforations in demineralized bone became centers of osteoinduction. Demineralized bone sterilized with ethylene oxide by this method vigorously formed new bone.

Influence of postmortem time and temperature on osteoinductive activity of demineralized microperforated ethylene oxide-sterilized syngeneic bone implant in the rat.

Bone morphogenetic protein is labile and easily inactivated by many extracorporeal factors. It is crucial to establish whether delay in retrieval of donor bone and ambient holding temperature of the donor body influence osteoinductivity of bone left in situ. Of ten adult rats that were killed, five were kept at 4 degrees and five at room temperature. Femurs were harvested at 24, 36, 48, 72, and 168 hours. After processing, segments were implanted in 20 four-week-old syngeneic rats for 14 days. The level of osteoinduction was evaluated histologically. It was excellent in the 4 degrees group in the 24-, 36-, and 48-hour specimens but less advanced at 72 hours. Bone taken from the room temperature group showed findings identical to those kept at 4 degrees through 36 hours, but osteoinduction was less advanced at 48 hours and absent at 72 hours. No bone formed at 168 hours in either temperature group. The following observations were made. (1) Osteoinductivity of demineralized bone left in situ after death was unexpectedly stable. (2) Retrieval time was extended by donor cooling. (3) Microperforated demineralized bone actively induced new bone formation. (4) Ethylene oxide does not inhibit osteoinduction when correctly applied for sterilization. If confirmed in humans, retrieval of bone to be used for osteoinduction could be delayed for some hours, particularly if the donor was immediately refrigerated. This would increase the effective number of bone tissue donors and utilize an undeveloped resource.

Alstroemeria. A new and potent allergen for florists.

Alstroemeria (Peruvian or Inca lily) has found particular favor because of its beauty and durability. However, it may induce a dermatitis so severe that workers have to change jobs. The dermatitis is chronic, with fissuring at the tips of the fingers bilaterally. Itching is often a less prominent symptom. Preventative measures are of little benefit, and many floral shops are vanishing the plant.

Adverse reactions to cosmetics.

Adverse reactions to cosmetics can be irritant or allergic and are most often caused by fragrances or preservatives. Preservatives include formaldehyde, formaldehyde releasers, and parabens. Other agents that cause allergy are paraphenylenediamine in hair dyes and toluene sulfonamide formaldehyde resin in nail polishes.

Perforated demineralized bone matrix: a new form of osteoinductive biomaterial.

This study was undertaken to evaluate a new osteoinductive material--perforated decalcified bone matrix (PDBM). Subcutaneous implantation of PDBM induces multiple centers of endochondral osteogenesis with subsequent resorption of bone matrix and its replacement by new bone. PDBM should therefore prove useful as a research model to study osteoinduction and in the clinical situation in orthopedic and reconstructive surgery for the filling of bone defects and stimulation of fracture healing.

Herpes zoster: a possible early clinical sign for development of acquired immunodeficiency syndrome in high-risk individuals.

Zoster is uncommon before the age of 50 years in immunologically normal individuals, but it occurs with increased frequency in people who are immunosuppressed. A retrospective review of 300 patients with acquired immunodeficiency syndrome associated with Kaposi's sarcoma, revealed that 8% had prior zoster, a rate that is sevenfold greater than historic controls of the same age. We prospectively examined forty-eight patients, with no known immunodeficiency or signs of AIDS or AIDS related complex (ARC), who presented with zoster localized to the thoracic region. Forty-one patients had known risk factors for AIDS and thirty-five had antibody to the AIDS-associated virus (AAV) at the time of presentation. One seropositive subject had no known risk factors. Absolute lymphocyte counts, lymphocyte OKT4/OKT8 ratios, and lymphocyte mitogen responses were all depressed in subjects with antibody to AAV when compared with seronegative individuals. Seven of thirty-three AAV antibody-positive subjects, who could be followed longitudinally, developed AIDS from 1 to 28 months (mean = 13) after zoster. One antibody-negative subject seroconverted to become AAV seropositive 16 months after zoster and developed Kaposi's sarcoma 1 month later. These eight subjects had persistently low lymphocyte OKT4/OKT8 ratios and elevated beta-2 microglobulin. In patients at risk for AIDS, the occurrence of zoster may be one sign that heralds the marked depression of cellular immunity associated with AIDS or ARC.

The effect of aging on bone formation in rats: biochemical and histological evidence for decreased bone formation capacity.

Ectopic bone formation by subcutaneously implanted demineralized bone matrix powder (DBM) was assessed biochemically and histologically in Fischer 344 rats of different ages. The total calcium accumulated in implants was greatly depressed in older rats, as was the rate of 45Ca deposition. High alkaline phosphatase activity appeared later in the 10- and 16-month-old rats compared with 1-month-old rats, and the magnitude of the alkaline phosphatase activity was decreased in 16-month-old rats. The accumulation of the bone-specific vitamin K-dependent bone protein (bone gla protein, BGP) was decreased in the implants in older rats. Histological examination of the implants confirms the decreased ability of aged animals to produce bone in response to DBM. Measurements of total calcium, alkaline phosphatase, and BGP at the site of demineralized bone matrix implants clearly demonstrates that bone formation decreases dramatically with increasing age. Significant differences in total calcium can be detected even between 1-month-old and 3-month-old rats. Serum BGP shows a marked decrease (47%) between 1-month- and 3-month-old rats, a decrease not paralleled by a similar decrease in BGP present in calvarial or tibial bone.

Toxic reactions evoked by glutaraldehyde-fixed pericardium and cardiac valve tissue bioprosthesis.

Bovine pericardial tissue and tissue-derived bioprosthesis fixed in glutaraldehyde and stored in either glutaraldehyde or formaldehyde can induce cytotoxic reactions even after prolonged washing due to the slow leaching of the chemicals used for crosslinking and sterilizing. Sequential rinsing for up to 60 min was still not sufficient to eliminate cytotoxic effects. On the other hand, satisfactory results were obtained when cardiac valves made from glutaraldehyde fixed pericardium were stored in a solution containing 0.02% of propyl-hydroxy-benzoate and 0.18% methyl-hydroxy-benzoate. The valves stored in this solution and rinsed three times for 1 min in normal saline showed few signs of residual cytotoxicity. Rinsing in a solution containing glycine was partially effective in neutralizing the cytotoxic effect, and this or similar approaches offer good possibilities. The use of Chang cells grown in culture provides an excellent quantitative assay for the assessment of residual cytotoxicity and for evaluating the host response to different methods of fixation, storage, and rinsing of tissue derived bioprosthesis.