Comparison of total and partial traumatic tears of the subscapularis tendon.

We treated surgically 16 shoulders with an isolated traumatic rupture of the subscapularis tendon over a six-year period. Nine patients had a total and seven a partial tear of the subscapularis tendon. Repair was undertaken through a small deltopectoral groove approach. The mean Constant score improved in total tears from 38.7 to 89.3 points (p = 0.003) and in partial tears from 50.7 to 87.9 points (p = 0.008). The total tears were significantly more improved by surgery than the partial tears (p = 0.001). The delay between trauma and surgery was inversely proportional to the improvement in the Constant score suggesting that early diagnosis and surgical repair improves outcome.

Transplantation of IL-2-transduced murine bone marrow is associated with dose-dependent toxicity.

OBJECTIVE: The purpose of this study was to investigate the effects of interleukin-2 (IL-2) gene-transduced hematopoietic progenitor cells or cytotoxic function and systemic toxicity following syngeneic bone marrow transplantation. MATERIAL AND METHODS: Marrow of 5-fluorouracil pretreated donor mice were transfected with a retroviral vector containing the murine IL-2 gene and transplanted into lethally irradiated syngeneic hosts. RESULTS: Productive insertion of the IL-2 gene could be demonstrated at various intervals post-transplant without impairment of hematopoietic engraftment. Endogenously augmented IL-2 release resulted in a selective increase in CD4(+), CD8(+), and NK1.1(+) population in spleen and bone marrow, as well as significant cytolytic activity against syngeneic leukemia cells in vitro. Our results also illustrate the interdependence among the magnitude of systemic IL-2 levels, the number of IL-2-transduced cells in the transplant inoculum, and the appearance of systemic toxicity. Infusion of marrow transduced with high-titer, high-expressing IL-2 retrovirus resulted in significant morbidity and mortality in the recipients. Our studies demonstrate that mortality was secondary to severe lymphocytic infiltration of liver and lung, which was associated with increased expression of intercellular adhesion molecule-1 and vascular adhesion molecule-1. Reducing the number of IL-2-transduced cells in the bone marrow inoculum, however, resulted in significantly improved survival with no adverse events being evident during the post-transplant period. CONCLUSION: Delivery of IL-2 to the bone marrow can be achieved by transplantation of genetically modified hematopoietic cells, however, the overall feasibility is strongly influenced by the number of transduced cells in the bone marrow inocolum and/or the expression pattern of IL-2 in vivo.

Immune response modulation by pentoxifylline in vitro.

Pentoxifylline (PTX) has recently been shown to modulate TNF-alpha production and to reduce the incidence and severity of all major complications after BMT, including mucositis, veno-occlusive disease, renal insufficiency, hypertension, and graft-versus-host disease. To analyze in detail the effect of PTX on immune complications after BMT, we investigated the immunomodulatory effect of PTX on immune responses in vitro. The continuous presence of PTX significantly reduced the proliferative response of PBMC to PHA stimulation and to alloantigens in a dose-dependent manner. Starting at concentrations of 100 micrograms/ml, PTX was able to inhibit and, at 1000 micrograms/ml, completely block mitogen-induced proliferation. Maximal inhibition of more than 90% (91 +/- 4%) was also observed at PTX concentrations of 1000 micrograms/ml in the mixed lymphocyte culture (MLR) and by addition on day 0. However, lower but still significant suppression (13 +/- 7%) was achieved at concentrations of 10 micrograms/ml PTX. The inhibitory capacity of PTX was increased by mAbs against TNF-alpha (34 +/- 5% additional suppression at 100 micrograms/ml PTX) and not reversed by the addition of rTNF-alpha. The effect of PTX on the generation of CTLs in vitro was studied in the cell-mediated lymphotoxicity assay. PTX (100 micrograms/ml) significantly inhibited (P = 0.0178) the in vitro generation of CTLs when PTX was added to the culture on day 0. PTX also showed profound modulatory properties in the NK assay, with a reduction of 23 +/- 3% in specific lysis at 10 micrograms/ml PTX and maximal reductions of 88 +/- 3% at 1000 micrograms/ml PTX. Immunomodulatory properties of PTX were not only associated with blockage of TNF-alpha, as shown by decreased mRNA expression and TNF-alpha values in the culture supernatants, but also with an impaired production of other cytokines and secondary messages such as IFN-gamma and neopterin. PTX treatment, however, did not affect IFN-alpha or IL-1 beta production, and IL-6 release was even increased. PTX, therefore, has profound immunomodulatory properties in vitro, which are associated with selective inhibition of cytokine release and can be enhanced by the addition of mAbs against TNF-alpha, but not reversed by the addition of rTNF-alpha.

CD34+-selected autologous peripheral blood stem cell transplantation (PBSCT) in patients with poor-risk hematological malignancies and solid tumors. A single-centre experience.

Between July 1994 and December 1996, PBSC were mobilized in 28 patients with poor-risk hematological malignancies and solid tumors. CD34+ cells were positively immunoselected using the Ceprate CS System. By December 1996, 22 patients had been reinfused with a median of 3.325 (0.078-9.5) x 10(6)/kg CD34+ cells. In three patients unselected back-up PBSC had to be transfused along with selected CD34+ cells because of a CD34+ cell number <0.5 x 10(6)/kg. G-CSF (10 microg/kg) was started on day +1 and all patients engrafted within a median day number of 12 (range, 10-22) until leukocytes >1.0 x 10(9)/l and a median day number of 56 (range, 10-180) until platelets >20.0 x 10(9)/l (ie platelet transfusion independence). Time to leukocyte and platelet recovery was significantly shorter in patients receiving >2.0 x 10(6)/kg purified CD34+ cells as compared to patients reinfused with <2.0 x 10(6)/kg CD34+ cells. The hematopoietic recovery time was similar to that of 18 historical control patients treated with unseparated ABMT +/- PBSCT with the exception of a significantly faster leukocyte engraftment in patients receiving >2.0 x 10(6)/kg CD34+ cells and a significantly delayed platelet recovery time in patients receiving <2.0 x 10(6)/kg purified CD34+ cells. There was a trend for a better overall survival and a lower probability of progression/relapse as compared to the historical controls. We observed five episodes of serious opportunistic infections (three pulmonary fungal infections, two cases of cryptosporidiosis) after the take. Four of these patients had been reinfused with <2.0 x 10(6)/kg CD34+ cells probably indicating a delayed immune reconstitution after CD34+-selected PBSCT.

Endurance sports after total knee replacement: a biomechanical investigation.

PURPOSE: No biomechanical evaluation of total knee designs exists for loads occurring during sports activities. It was the purpose of the present study to evaluate the contact stress distribution and contact area of different knee joint designs for loads that occur during four common recreational endurance activities. METHODS: Three different total knee designs were evaluated for loads occurring during cycling (1.2 body weight (BW) at 80 degrees of knee flexion), power walking (4 BW at 20 degrees), hiking (8 BW at 40 degrees), and jogging (9 BW at 50 degrees) using Fuji pressure-sensitive film. The designs consisted of a flat tibial inlay, a curved inlay, and an inlay with mobile bearings. Five measurements were conducted for each load. The pressure sensitive films were scanned and analyzed using an image analysis program. RESULTS: During cycling, the area with stress levels above the yield point of polyethylene (overloaded area) was below 15 mm2 for each design. During power walking, the mobile bearing design showed no overloaded area, whereas it was below 50 mm2 for the flat and curved design. During downhill walking and jogging, more than 140 mm2 were overloaded for each design. CONCLUSIONS: It was concluded that patients after total knee replacement should alternate activities such as power walking and cycling. For mountain hiking, patients are advised to avoid descents or at least use ski poles. Jogging or sports involving running should be discouraged after total knee replacement.

The benefits of wearing a compression sleeve after ACL reconstruction.

PURPOSE: It was the purpose of the present study to examine the possibility of increased muscle coordination after anterior cruciate ligament (ACL) reconstruction through the wearing of a compression sleeve. METHODS: Thirty-six patients were studied who had undergone unilateral ACL reconstruction at least 12 months previously. All subjects were required to perform a 10-cm standing drop jump from an elevated platform onto a force plate, to land on one leg, and thereafter maintain a one-legged balance for 25 s. This task was repeated three times without and three times with an elastic compression sleeve worn on the reconstructed limb. For analysis, the task was partitioned into a landing phase (150 ms), an adjusting phase (10s), and a balancing phase (10s). The peak impact loadings were measured in each direction (Fx, Fy, and Fz) during landing, while force-time integrals (intFz, intFy, and intFz) and root mean square (RMS) error of these forces were calculated for the adjusting and balancing phases. The path length and RMS of the center of pressure coordinates (Ax and Ay) were obtained for the adjusting and balancing phases combined. RESULTS: Drop landings with the bandage produced significantly larger (P < 0.001) peak ground reaction forces in the vertical and anteroposterior direction, suggesting increased subject confidence in their knee. Wearing the knee bandage also enabled the patients to reduce all measured parameters in the anteroposterior direction (rmsFx, intFx, rmsAx) during both the adjusting and balancing phases (P < 0.001 ). A significant reduction in the center of pressure path length further indicated an enhanced steadiness during the one-legged stance. CONCLUSIONS: It was concluded that a compression sleeve improved the total integration of the balance control system and muscle coordination.

Cyclosporin A and osteonecrosis of the femoral head.

A vascular osteonecrosis has occurred in 5 to 40 per cent of patients who have undergone transplantation of a kidney and generally has been considered to be a complication of the use of corticosteroids. Currently cyclosporin A is in general use for its immunosuppressive property, so that a lower dose of corticosteroids is needed. We analyzed the cases of a series of our patients who underwent transplantation of a kidney in order to find out if our present regimen, using cyclosporin A, influenced the prevalence of osteonecrosis of the femoral head. Of a total of 270 patients, osteonecrosis of the femoral head developed in fifteen of 174 who received conventional immunosuppressive therapy and in only one of ninety-six who received cyclosporin A (p less than 0.05). During the first two months after transplantation, the mean dose of prednisone was approximately 2.5 milligrams per kilogram of body weight per day in the group that received conventional immunosuppressive therapy and approximately 1.1 milligrams per kilogram of body weight per day in the group that received cyclosporin A (p less than 0.001). We concluded that the pathogenesis of the osteonecrosis in patients who underwent transplantation of a kidney was probably related to the higher doses of corticosteroids that were administered.

Spin-echo and 3D gradient-echo imaging of the knee joint: a clinical and histopathological comparison.

OBJECTIVE: A clinical and histopathological comparison of 2D spin-echo (SE) and 3D gradient-echo (3DGE) sequences was undertaken for the knee joint. The purpose of the study was to evaluate the clinical results and to explain the different appearances of meniscal abnormalities on both 2DSE and 3DGE images. PATIENTS, MATERIALS AND METHODS: The clinical study comprised 45 patients with arthroscopically correlated MR imaging results. For the histopathological correlation, seven cadaveric knee joints were examined with the same 2DSE and 3DGE (FISP) imaging protocol and sliced in sagittal sections according to the MR images. Different stainings were used. RESULTS: For the detection of meniscal tears, accuracy (82.2%) and positive predictive value (70.7%) of the 3DGE sequence were limited due to a high number of false positive findings. Cartilaginous lesions were more easily visible on 3DGE than on 2DSE images (sensitivity: 63.1% vs. 52.6%, respectively). As in the clinical study, the meniscal signal abnormalities of the cadaveric knee joints were much more extensive on the 3DGE images than on the 2DSE images. The 3DGE findings correlated better with degenerative meniscal changes which were visible microscopically. CONCLUSION: The high sensitivity of the 3DGE sequence for degenerative meniscal changes explains the lack of specificity for the differentiation between meniscal degeneration and tears with this sequence. The MR grading system for meniscal lesions is of limited value for the evaluation of 3D FISP images.

Arthroscopic findings after shoulder dislocation.

The purpose of this study was to evaluate prospectively the arthroscopic findings of the unstable shoulder, to provide insights into the causes and mechanisms of shoulder instability, and to establish a rationale for using special surgical procedures. Arthroscopic examination was performed on 212 patients who had at least 1 documented shoulder dislocation. Of these 212 patients, 184 (87%) patients had anterior glenoid labral tears, 168 (79%) patients had ventral capsule insufficiency, 144 (68%) patients had Hill-Sachs compression fractures, 116 (55%) patients had glenohumeral ligament insufficiency, 30 (14%) patients had complete rotator cuff tendon tears, 26 (12%) patients had posterior glenoid labral tears, 14 (7%) patients had superior labrum anterior and inferior lesions. As this prospective study shows, multiple morphologic changes are associated with instability of the glenohumeral joint; there is no single cause for an unstable shoulder. Arthroscopic examination of the shoulder before surgery revealed a significant amount of information that would have been undetected without the aid of expensive diagnostic tools. For instance, the labrum and rim of the anteroinferior glenoid showed typical abnormalities corresponding to different entities of anterior instability.

Joint load considerations in total knee replacement.

Estimates of knee joint loadings were calculated for 12 normal subjects from kinematic and kinetic measures obtained during both level and downhill walking. The maximum tibiofemoral compressive force reached an average load of 3.9 times body-weight (BW) for level walking and 8 times BW for downhill walking, in each instance during the early stance phase. Muscle forces contributed 80% of the maximum bone-on-bone force during downhill walking and 70% during level walking whereas the ground reaction forces contributed only 20% and 30% respectively. Most total knee designs provide a tibiofemoral contact area of 100 to 300 mm2. The yield point of these polyethylene inlays will therefore be exceeded with each step during downhill walking. Future evaluation of total knee designs should be based on a tibiofemoral joint load of 3.5 times BW at 20 degrees knee flexion, 8 times BW at 40 degrees and 6 times BW at 60 degrees.

Arthroscopic findings in acute fractures of the ankle.

We have evaluated prospectively the arthroscopic findings in acute fractures of the ankle in 288 consecutive patients (148 men and 140 women) with a mean age of 45.6 years. According to the AO-Danis-Weber classification there were 14 type-A fractures, 198 type B and 76 type C. Lesions of the cartilage were found in 228 ankles (79.2%), more often on the talus (69.4%) than on the distal tibia (45.8%), the fibula (45.1%), or the medial malleolus (41.3%). There were more lesions in men than in women and in general they were more severe in men (p < 0.05). They also tended to be worse in patients under 30 years and in those over 60 years of age. The frequency and severity of the lesions increased from type-B to type-C fractures (p < 0.05). Within each type of fracture the lesions increased from subgroups 1 to 3 (p < 0.05). The anterior tibiofibular ligament was injured with increased frequency from type-B.1 to type-C3 fractures (p < 0.05), but it was not torn in all cases. While lateral ligamentous injuries were seen more often in type-B than in type-C fractures (p < 0.05), no difference was noted in the frequency of deltoid ligamentous lesions. Our findings show that arthroscopy is useful in identifying associated intra-articular lesions in acute fractures of the ankle.

The first metatarsal rise sign: a simple, sensitive sign of tibialis posterior tendon dysfunction.

Although foot deformation starts in the early stage of tibialis posterior (TP) tendon dysfunction, this condition is often overlooked or misdiagnosed. We observed consistently a clinical sign of TP tendon dysfunction that, to our knowledge, has not yet been described. Patients were tested while they were standing and fully weight-bearing with both feet. When the shank of the affected foot was taken with one hand and externally rotated, or when the heel of the affected foot was taken with one hand and brought passively into a varus position, the head of the first metatarsal raised in the case of TP dysfunction and remained on the ground in normal TP function. The purpose of this prospective study was to validate this clinical finding by surgical exploration, and to compare its sensitivity with other common clinical signs. Our series included 21 consecutive feet with TP tendon dysfunction (19 patients). The deformity was supple in 12 feet and fixed in 9 feet. Radiographs and magnetic resonance imaging were found to be unreliable in diagnosing dysfunction of the TP tendon. While other clinical signs (too many toes, the single-heel rise, and the double-heel rise) were noted to be negative in 20% to 35%, we found our first metatarsal rise sign to be positive in all cases of TP tendon dysfunction. This simple clinical test enables us to recognize and treat a dysfunction of the TP tendon at an early stage, when the foot is still supple. As the foot deformation progresses, early treatment may be the most effective measure in preventing long-term functional impairment.

[The first dislocation of the shoulder]. / Erstluxation der Schulter.

The classical anterior-inferior dislocation of the shoulder is diagnosed easily by clinical examination and x-ray. The additional lesions like impression fracture at the humerus, avulsion of the anterior rim of the glenoid, lesions of the rotator cuff or neurologic deficits are more difficult to realise. In young patients the redislocation rate is rather high. Indication for surgery is still on debate. Modern diagnostic tools will help to determine additional lesions. More problems are incountered in presence of a posterior dislocation. Those are often overlooked.

[Rehabilitation following arthroscopic interventions]. / Rehabilitation nach arthroskopischen Eingriffen.

The view that postoperative treatment is unnecessary after arthroscopically controlled operations is mistaken. On the contrary, the success of an arthroscopic operation depends to a large extent on effective after-treatment. Arthroscopic operations can be divided into three main groups: Group I Partial and complete meniscectomies, removal of floating bodies, plica resection, lateral incision of the retinaculum Group II Synovectomy, shaving, and chondroplasty Group III Meniscus refixation, replacement of the anterior cruciate knee ligament.

[Arthroscopy of smaller joints: hand, elbow and ankle arthroscopy]. / Arthroskopie kleiner Gelenke: Hand- bzw. Ellbogen- und Sprunggelenkarthroskopie.

These joints are accessible, though technically demanding, by arthroscope. Above all, the evaluation of the lesions is not simple. Arthroscopy always represents the last diagnostical alternative. The extraction of loose fragments, the debridement, the shaving and the treatment of infections are excellent indications. Postoperative rehabilitation is favoured and shortened with the arthroscopic approach. Elbow arthroscopy did not greatly, develop during the last years. Posttraumatic situations, corpora libera and cartilage lesions represent the main indications. The arthroscopies of the ankle and the wrist, however, are increasing. Carpal instability and discus problems of the wrist are quite interesting. Lately, endoscopic carpal-tunnel decompression has been propagated, but is still in its experimental phase. At the ankle, osteochondrosis dissecans, flake fracture and fibrosed plica [discovered through arthroscopy, mostly in athletes] are suitable for arthroscopic removal or reconstruction. Interfering osteophytes at the anterior border of the tibia can also be removed arthroscopically. Percutaneous internal fixation and fusion of the ankle joint need first to be evaluated in a long-term follow-up. Arthroscopic debridement and rinsing against infections are quite successful for all the joints. The arthroscopy of a small joint is technically quite demanding; therefore, it should be practised only by a few specialized centres.