Ultrasonography in a Senegalese community recently exposed to Schistosoma mansoni infection.

Inhabitants of Ndombo (n = 614), a village in an area recently infected with Schistosoma mansoni in Northern Senegal, were examined clinically, parasitologically, and ultrasonographically to investigate the presence and degree of S. mansoni-related hepatosplenic morbidity after a few years of exposure to schistosomal infection of regional canals. Despite previous praziquantel treatment of 56% of the inhabitants prior to our investigation, the prevalence of S. mansoni infection in 1993 was 90%, and 42% of the villagers excreted more than 1,000 eggs per gram of stool. Previously untreated individuals were found to have significantly higher egg counts than treated ones. Despite the high intensities of infection, ultrasonographically detected severe periportal thickening of the liver was infrequent. Grading according to body length-dependent normal values of cross-section diameter of peripheral portal vein branches of a European control group correlated with intensities of infection. Of the total group of patients, 30% (n = 182) had more severe thickening of portal vein branch diameters above the 97th percentile and 70% of these had a splenomegaly. The highest egg counts and the most frequent development of periportal thickening were found in 11-20 year-old individuals. Periportal thickening was less frequent in praziquantel-treated adolescents than in untreated ones. This suggests that early antischistosomal medication may be useful to limit schistosomiasis-induced hepatic morbidity especially in children, even though reinfection seems inevitable.

Displaced fractures of the radial neck in children: long-term results and prognosis of conservative treatment.

Fractures of the radial head or neck in children may lead to radial head deformity and loss of pronation and supination. Trauma may not only be caused by the injury itself, but also may occur secondarily to surgical reduction and manipulation of fracture fragments. Thirty-eight children with displaced radial neck fractures were investigated 2 to 20 years after the initial accident. Whereas radial head deformity was present in 83% of cases, functional disorder was found in only four children (11%). These children had either developed secondary growth disturbances, which had led to a radioulnar synostosis in one case, or they had been treated by open surgical reduction. On follow-up radiographs, all conservatively treated fractures with angulation up to 50 degrees had corrected themselves spontaneously. The high complication rate after open reduction and the poor functional results and inconvenience for the pediatric patient makes conservative treatment of radial neck fractures in children preferable.

Posttraumatic elbow deformities in children.

In the last 20 years 49 children with gross posttraumatic elbow deformities have been treated in our hospital: 19 patients with an overlooked radial head dislocation, 12 children with a radial condyle deformity and 19 patients with a severe radial head deformity. Secondary treatment: In the majority of cases secondary surgical procedures led to unsatisfying results. Only 4 patients with a pseudarthrosis of the radial condyle were treated secondarily. Surgical fixation led to good functional results but was not able to remove the joint deformity. Overlooked radial head dislocations were treated by ulnar osteotomy in 17 cases. We were able to follow up 13 of these: a redislocation had taken place in 8 of them. Functional impairment was found in 6 redislocated cases and in 2 children with a correct position of the radial head. In patients with gross radial head deformities arthrolysis was performed. The radial head had to be taken out in 7 cases. Functional results of pro- and supination were unsatisfactory. Initial treatment and causes: Persistent dislocations of the radial head had been overlooked initially. In 9 out of 12 cases with a radial condyle deformity a conservatively treated dislocated fracture had led to a pseudarthrosis. In the remaining 2 cases the fracture fragments had been fixated in an incorrect position. Radial head deformities were seen after dislocated radial head fractures which had been treated by open reduction, internal fixation, longterm immobilization (6-8 weeks) and excessive physiotherapy. CONCLUSION: In 47 out of 49 cases posttraumatic deformities were either caused by delayed an neglected treatment or traumatic and excessive therapy methods. An adequate initial diagnosis and therapy can prevent more than 90 % of severe posttraumatic elbow deformities in children.

Osseous overgrowth after post-traumatic amputation of the lower extremity in childhood.

Severe accidents in children may cause extreme destruction of the lower extremities. In some cases, there is no possibility to preserve the limbs. Initially, a weight-bearing stump cannot be achieved after amputation due to unstable local and soft tissue conditions. This critical situation is often complicated by one of the leading problems in the limb-deficient child - the development of osseous overgrowth. Bizarre overgrowth of the stump may lead to skin perforation, pressure ulcers, and difficulties with the prosthesis. Since 1993, we have been able to follow five pediatric and adolescent patients (2 years to 17 years old) with six post-traumatic amputations of the lower extremities. Four of these cases developed osseous overgrowth. One child treated with initial autologous stump-capping had excellent soft tissue conditions and no problems with the artificial limb. We also report on a case of bizarre and extensive new bone formation. We conclude that close follow-up visits after post-traumatic amputations in children are essential because of new bone formation which may endanger the soft tissue situation of the stump. Unfortunately, surgical revisions have to be performed quite often. To avoid several surgical corrections, an initial stump-capping with autologous material from the injured limb can be performed. Thus, the number of secondary procedures may be reduced drastically.

Prevention of skin and soft tissue entrapment in tibial segment transportation.

We report of a ten year old patient with soft tissue damage and bone defect of the tibia as a sequel of osteomyelitis. After excision and stabilization with an Ilizarov fixateur segment transportation was started. In order to avoid skin and soft tissue entrapment in the docking region, we used a metal cage as a space provider, which was shortened as segment transportation progressed. To our knowledge this simple method has not been described so far.

[Post-traumatic problem cases involving the elbow in children]. / Posttraumatische Problemfälle am kindlichen Ellbogen.

In the last 20 years 49 children with gross posttraumatic elbow deformities have been treated in our hospital: 19 patients with an overlooked radial head dislocation, 12 children with a radial condyle deformity and 19 patients with a severe radial head deformity. SECONDARY TREATMENT: In the majority of cases secondary surgical procedures led to unsatisfying results. Only 4 patients with a pseudarthrosis of the radial condyle were treated secondarily. Surgical fixation led to good functional results but was not able to remove the joint deformity. Overlooked radial head dislocations were treated by ulnar osteotomy in 17 cases. We were able to follow up 13 of these: a redislocation had taken place in 8 of them. Functional impairment was found in 6 redislocated cases and in 2 children with a correct position of the radial head. In patients with gross radial head deformities arthrolysis was performed. The radial head had to be taken out in 7 cases. Functional results of pro- and supination were unsatisfactory. INITIAL TREATMENT AND CAUSES: Persistent dislocations of the radial head had been overlooked initially. In 9 out of 12 cases with a radial condyle deformity a conservatively treated dislocated fracture had led to a pseudarthrosis. In the remaining 2 cases the fracture fragments had been fixated in an incorrect position. Radial head deformities were seen after dislocated radial head fractures which had been treated by open reduction, internal fixation, longterm immobilization (6-8 weeks) and excessive physiotherapy. CONCLUSION: In 47 out of 49 cases posttraumatic deformities were either caused by delayed an neglected treatment or traumatic and excessive therapy methods. An adequate initial diagnosis and therapy can prevent more than 90% of severe posttraumatic elbow deformities in children.

[Prognosis of proximal radius fractures in the growth period]. / Die Prognose proximaler Radiusfrakturen im Wachstumsalter.

Fractures of the proximal radius in children may lead to deformities of the radial head and functional disturbance of pro- and supination. However, traumatization is not only caused by the injury itself, but may also occur secondary to surgical reduction, manipulation of fracture fragments and excessive physiotherapy. In a prospective long-term follow-study (2-20 years after trauma) of 38 children with displaced proximal radius fractures we found functional disturbances in 11% of children only. These were not caused by radial head deformities, which were present on 83% of follow-up radiographs. Functional impairment was mainly seen after open reduction or secondary growth disturbances. On follow-up radiographs all conservatively treated fracture angulations up to 60 degrees had corrected themselves spontaneously. In view of the high complication rates after open reduction and the poor functional results, as well as the inconvenience for the pediatric patient and the economic aspects, we recommend a primary conservative treatment concept of proximal radius fractures in children.

Sonographic measurements of the portal vein and its intrahepatic branches in children.

Dilatation of the portal vein is a leading sonographic sign in portal hypertension. Enlargement of its intrahepatic branches is found in various liver diseases such as cystic fibrosis and hepatic schistosomiasis. However, body height dependent values for pathological portal vein diameters on ultrasound have been published for adults only and reference values for intrahepatic portal vein branches have to be established. Diameters of the portal vein and of peripheral portal vein branches were investigated in 130 healthy European children and adolescents by ultrasound. The findings correlated significantly with age and body height. Thus, height related diameter values should be used to define pathological enlargement of the portal vein and its intrahepatic branches in children. Our reference data may contribute to improve sonographical investigation of portal hypertension and periportal fibrosis.

[Standardized sonographic investigation of the lumbar spine in 247 newborns]. / Standardisierte sonographische Primäruntersuchung der lumbalen Wirbelsäule bei 247 Neugeborenen.

Open dysraphism is generally known before birth due to prenatal screening but occult spinal malformation often remains unrecognized. Nevertheless, newborns with occult dysraphism could be easily diagnosed by ultrasound, which might be performed additionally to the neonatal screening of the hips. Early surgical treatment or close neuropediatric follow-ups could be administered as a consequence. As part of a prospective study-design, we screened the spinal cord of 247 newborns by ultrasound. Parents were interviewed about a positive family history, a folate intake during pregnancy, amniocentesis or chorionbiopsy. Clinically, cutaneous stigmata usually associated with occult spinal dysraphism were evaluated. An orthopedic and pediatric examination followed. The sonographic investigation was done in prone position using a newly designed positioning device. The sonographic examination was performed within 5 minutes and longitudinal and transversal pictures were taken for documentation. In all of the 247 examined newborns we were able to visualize the cartilageous structures of the spinal cord and the dural sack detailly. Dependent on the position of the newborn, variations of the width of the dural sack could be noted. Thus a newly designed positioning device helped to standardize the examination situation. We did not find any pathological changes of the spinal cord. Nevertheless ultrasonography provides a useful diagnostic tool in investigating the newborn where occult spinal dysraphism is expected.

Osteoblast response to titanium surface roughness and 1alpha,25-(OH)(2)D(3) is mediated through the mitogen-activated protein kinase (MAPK) pathway.

When osteoblasts are cultured on surfaces of increasing microroughness, they exhibit decreases in proliferation, increases in differentiation and local factor production, and enhanced response to 1alpha,25(OH)(2)D(3). The cells interact with surfaces through integrins, which signal by the same pathways used by 1alpha,25(OH)(2)D(3), including protein kinase C via phospholipase C and protein kinase A via phospholipase A(2). This provides opportunities for crosstalk that may contribute to the synergistic effects of surface roughness and the vitamin D metabolite. Because these pathways converge at mitogen-activated protein kinase (MAPK), we tested the hypothesis that the extracellular signal-regulated kinase (ERK1/2) subclass of MAPKs mediates the effects of surface roughness and 1alpha,25(OH)(2)D(3). MG63 osteoblast-like osteosarcoma cells were cultured on commercially pure Ti disks with various surface roughnesses: pretreatment (PT; 0.6 microm average roughness [Ra]), coarse grit-blasted and acid-etched (SLA; 4 microm RA), and titanium plasma-sprayed (TPS; 5.2-microm R(a)). At confluence, cells were treated for 24 h with control media or media containing 10(-7) M 1alpha,25(OH)(2)D(3). One-half of the cultures received 1 microm or 10 microm PD98059, a specific inhibitor of the ERK family of MAPKs. PD98059 alone did not affect proliferation, osteocalcin production, or production of transforming growth factor-beta1 or nitric oxide, regardless of the surface roughness. Alkaline phosphatase was reduced by the inhibition of the ERK family kinases on all surfaces to a comparable extent. However, when PD98059 was added to the cultures with 1alpha,25(OH)(2)D(3), the effects of the seco-steroid were blocked, including the synergistic increases seen in MG63 cells cultured on SLA or TPS. These results indicate that ERK1/2 MAPK is required for the maintenance of alkaline phosphatase at control levels and that the effects of 1alpha,25(OH)(2)D(3) are mediated by ERK1/2. However, the effects of surface roughness are not due to the ERK family of MAPKs. This suggests that alternative pathways may be used, including those mediated by other MAPK subclasses.

Response of normal female human osteoblasts (NHOst) to 17beta-estradiol is modulated by implant surface morphology.

Titanium (Ti) surfaces with rough microtopographies enhance osteogenic differentiation, local factor production, and response to osteogenic agents in vitro and increase pullout strength of dental implants in vivo. Estrogens regulate bone formation, resorption, and remodeling in females and may be important in implant success. Here, we tested the hypothesis that estrogen modulates osteoblast response to implant surface morphology. Primary female human osteoblasts were cultured to confluence on three Ti surfaces (pretreatment, PT - R(a) 0.60 microm; sandblasted and acid-etched, SLA - R(a) 3.97 microm; and Ti plasma-sprayed, TPS - R(a) 5.21 microm) and treated for 24 h with 10(-7) or 10(-8) M 17beta-estradiol (E(2)). Cell number decreased with increasing surface roughness, but was not sensitive to E(2). Alkaline phosphatase specific activity of isolated cells and cell layer lysates was lower on rough surfaces. E(2) increased both parameters on smooth surfaces, whereas on rough surfaces, the stimulatory effect of E(2) on alkaline phosphatase was evident only when measuring cell layer lysates. Osteocalcin levels were higher in the conditioned media of cells grown on rough surfaces; E(2) had no effect in cultures on the plastic surfaces, but increased osteocalcin production on all Ti surfaces. TGF-beta1 and PGE(2) production was increased on rough surfaces, and E(2) augmented this effect in a synergistic manner; on smooth surfaces, there was no change in production with E(2). The response of osteoblasts to surface topography was modulated by E(2). On smooth surfaces, E(2) affected only alkaline phosphatase, but on rough surfaces, E(2) increased levels of osteocalcin, TGF-beta1, and PGE(2). These results show that normal adult human female osteoblasts are sensitive to surface microtopography and that E(2) can alter this response.