[Traumatic hemipelvectomy : An uncommon case in trauma surgery]. / Traumatische Hemipelvektomie : Ein nichtalltäglicher Fall in der Unfallchirurgie.

The challenge in treating traumatic hemipelvectomy is the dynamics of the complex and life-threatening consequences of the injury. These include skin and soft tissue defects, osseous, neural and vascular injuries as well as the subsequent hemostatic derangement and organ dysfunction as part of the shock process. The treatment requires rapid and targeted decisions to save the patient's life. In this particular case a 34-year-old farmer was trapped between a wheeled loader and a stationary trailer. Upon arrival at the hospital the patient was in a state of hemorrhagic shock with accompanying acute traumatic coagulopathy and a grade III open pelvic trauma with complete ischemia of the left leg and a bladder injury. After performing emergency surgery and a two-stage approach for pelvic stabilization the patient's condition deteriorated up to multiorgan failure, necessitating left-sided hemipelvectomy as an immediate life-saving salvage procedure. In the further course multiple revision surgeries and plastic reconstructions due to wound infections and the presence of skin and soft tissue damage were required. Due to the rare confrontation with this type of injury in everyday practice and the absence of a universal treatment algorithm, the following case report is intended to contribute to a better understanding of the treatment and to illustrate the coherent interactions of the individual organ systems affected.

QuickMap: a public tool for large-scale gene therapy vector insertion site mapping and analysis.

Several events of insertional mutagenesis in pre-clinical and clinical gene therapy studies have created intense interest in assessing the genomic insertion profiles of gene therapy vectors. For the construction of such profiles, vector-flanking sequences detected by inverse PCR, linear amplification-mediated-PCR or ligation-mediated-PCR need to be mapped to the host cell's genome and compared to a reference set. Although remarkable progress has been achieved in mapping gene therapy vector insertion sites, public reference sets are lacking, as are the possibilities to quickly detect non-random patterns in experimental data. We developed a tool termed QuickMap, which uniformly maps and analyzes human and murine vector-flanking sequences within seconds (available at www.gtsg.org). Besides information about hits in chromosomes and fragile sites, QuickMap automatically determines insertion frequencies in +/- 250 kb adjacency to genes, cancer genes, pseudogenes, transcription factor and (post-transcriptional) miRNA binding sites, CpG islands and repetitive elements (short interspersed nuclear elements (SINE), long interspersed nuclear elements (LINE), Type II elements and LTR elements). Additionally, all experimental frequencies are compared with the data obtained from a reference set, containing 1 000 000 random integrations ('random set'). Thus, for the first time a tool allowing high-throughput profiling of gene therapy vector insertion sites is available. It provides a basis for large-scale insertion site analyses, which is now urgently needed to discover novel gene therapy vectors with 'safe' insertion profiles.

A softening laminar electrode for recording single unit activity from the rat hippocampus.

Softening neural implants that change their elastic modulus under physiological conditions are promising candidates to mitigate neuroinflammatory response due to the reduced mechanical mismatch between the artificial interface and the brain tissue. Intracortical neural probes have been used to demonstrate the viability of this material engineering approach. In our paper, we present a robust technology of softening neural microelectrode and demonstrate its recording performance in the hippocampus of rat subjects. The 5 mm long, single shank, multi-channel probes are composed of a custom thiol-ene/acrylate thermoset polymer substrate, and were micromachined by standard MEMS processes. A special packaging technique is also developed, which guarantees the stable functionality and longevity of the device, which were tested under in vitro conditions prior to animal studies. The 60 micron thick device was successfully implanted to 4.5 mm deep in the hippocampus without the aid of any insertion shuttle. Spike amplitudes of 84 µV peak-to-peak and signal-to-noise ratio of 6.24 were achieved in acute experiments. Our study demonstrates that softening neural probes may be used to investigate deep layers of the rat brain.

Glucose and Stress Independently Regulate Source and Sink Metabolism and Defense Mechanisms via Signal Transduction Pathways Involving Protein Phosphorylation.

In higher plants, sugars are required not only to sustain heterotrophic growth but also to regulate the expression of a variety of genes. Environmental stresses, such as pathogen infection and wounding, activate a cascade of defense responses and may also affect carbohydrate metabolism. In this study, the relationship between sugar- and stress-activated signal transduction pathways and the underlying regulatory mechanism was analyzed. Photoautotrophically growing suspension culture cells of Chenopodium rubrum were used as a model system to study the effects of the metabolic regulator D-glucose and of different stress-related stimuli on photosynthesis, sink metabolism, and defense response by analyzing the regulation of mRNAs for representative enzymes of these pathways. Glucose as well as the fungal elicitor chitosan, the phosphatase inhibitor endothall, and benzoic acid were shown to result in a coordinated regulatory mechanism. The mRNAs for phenylalanine ammonia-lyase, a key enzyme of defense response, and for the sink-specific extracellular invertase were induced. In contrast, the mRNA for the Calvin cycle enzyme ribulose bisphosphate carboxylase was repressed. This inverse regulatory pattern was also observed in experiments with wounded leaves of C. rubrum plants. The differential effect of the protein kinase inhibitor staurosporine on mRNA regulation demonstrates that the carbohydrate signal and the stress-related stimuli independently activate different intracellular signaling pathways that ultimately are integrated to coordinately regulate source and sink metabolism and activate defense responses. The various stimuli triggered the transient and rapid activation of protein kinases that phosphorylate the myelin basic protein. The involvement of phosphorylation in signal transduction is further supported by the effect of the protein kinase inhibitor staurosporine on mRNA levels.

Osteonecrosis of the medial part of the tibial plateau.

Fifteen elderly patients (sixteen knees) were seen because of acute pain in the knee and tenderness to palpation over the medial aspect of the tibial plateau. Initially, plain roentgenograms showed a radiolucent area at the site of the tenderness in only nine of the sixteen knees. However, radionuclide bone scans showed focal increased uptake at the site of the tenderness in four of the seven remaining knees, and magnetic resonance images showed discrete areas of low signal intensity at the same site in the other three knees. Plain roentgenograms eventually showed the typical lesion in all knees. Progression of the symptoms led to a total knee arthroplasty in nine knees and to a unicompartmental replacement in three; a satisfactory result was obtained in all twelve knees. An operation was recommended for two other knees, but it was refused by the patients. The symptoms resolved spontaneously in the remaining two knees. A degenerative tear in the medial meniscus, which is a common finding in this age-group, was noted at the time of a later operation in the three knees that had not had a radiolucent area on the initial plain roentgenograms but that had had an area of low signal intensity on the magnetic resonance images. If osteonecrosis of the tibial plateau is not considered as a potential cause of pain in the knee, symptoms may be attributed to a tear in the meniscus and an unnecessary and unproductive arthroscopy may be performed.

Influence of positioning of prosthesis in total knee replacement.

The early clinical results of geometric total knee arthroplasty were compared with the position of the prosthetic device by a roentgenographic score system. It was noted that there is a statistically significant positive correlation between a good clinical result and a well positioned prosthesis. In addition, it was appreciated that perfect positioning of the device was difficult to obtain. We believe that the long-term clinical results, wear resistance, and resistance to prosthetic failure depend on correct positioning of the devices.

Painful knees in older patients: radionuclide diagnosis of possible osteonecrosis with spontaneous resolution.

The syndrome of osteonecrosis of the femur at the knee presents as sudden onset of knee pain in elderly patients. It is classically associated with a subchondral radiolucency and a positive radionuclide bone scan. The lesion may progress to collapse of the bone. In this report, twelve cases are described in which the clinical entity of osteonecrosis of the femoral condyle was diagnosed because the patients had a clinical picture identical to that of osteonecrosis and also had positive bone scans. However, roentgenographic changes supposedly diagnostic of the condition were not seen. In twelve patients, arthrotomy was avoided. They became asymptomatic and their bone scans returned to normal in a few months.

Late reconstruction of the patellar tendon.

Late reconstruction of undiagnosed ruptures of the patellar tendon by transfer of the gracilis and semitendinosus tendons, supplemented by a heavy-gauge encircling wire to bridge the gap, was successful in four patients. These tendons are stronger than fascial strips which have previously been used for the purpose. The four patients treated by this technique returned to their preinjury functional levels.

The treatment of trochanteric hip fractures using a compression screw.

One hundred and four consecutive intertrochanteric hip fractures treated with a compression screw were reviewed. Despite death and lack of follow-up, the late results in sixty-two cases of fracture were analyzed. Three non-unions and one malunion gave the technique a failure rate of only 6.4 per cent. Twenty-two patients with both stable and unstable fractures were allowed to bear weight as early as tolerated, in an average of fourteen days. Early weight-bearing did not appear to compromise the end result.

Indications for the treatment of deep venous thrombosis following total knee replacement.

The diagnosis of deep venous thrombosis in the lower extremity has usually been thought to mandate the initiation of anticoagulation therapy. However, there has been evidence to show that this approach may not be necessary for deep venous thrombosis at or distal to the knee, and that the risks of treatment may be greater than those of the thrombosis itself. One hundred and seventy-five patients who underwent total knee replacement were examined postoperatively by venography, plethysmography, fibrinogen scans, and ventilation-perfusion lung scans. We found that 126 (72 per cent) of them had small or large clots in the calf, and that only forty-nine (28 per cent) had no thrombi. Seventy-one (41 per cent) of the patients had small thrombi in the calf and fifty-five (31 per cent) had large thrombi in the calf. Six patients had thrombi in the thigh, all of which were associated with large thrombi in the calf. In only two patients, however, did clinically recognized pulmonary emboli develop, one in the group of patients without known thrombi and the other in a patient with a large iliofemoral thrombus. The ventilation-perfusion scans showed six asymptomatic pulmonary emboli that were not associated with the presence of either large or small thrombi in the calf. The fibrinogen scans that were done in the postoperative period were capable of revealing large but not small thrombi in the calf. The preoperative plethysmography did not aid in determining in which patients a large thrombus of the calf or thigh was likely to develop.(ABSTRACT TRUNCATED AT 250 WORDS)

Late results following medial meniscectomy in an older population.

We reviewed the cases of 101 patients who had an isolated medial meniscectomy after the age of forty-five years. Sixty-six patients were available for re-evaluation at an average of 10.8 years after operation. The patients were grouped according to preoperative radiographs. Patients with normal preoperative radiographs had a 90 per cent chance of having a good or excellent result, while patients with pre-existing moderate or marked degenerative changes had only a 21 per cent chance of a good or excellent result. The patient's age per se did not appear to affect the results, but pre-existing degenerative arthritis clearly diminished the quality of the result. Other causes of symptoms in the medial aspect of the joint, such as osteonecrosis, must be carefully excluded prior to meniscectomy in an elderly patient.

Complications of posterior arthrodesis of the cervical spine in patients who have Down syndrome.

Ten patients who had Down syndrome and had had a posterior arthrodesis of the upper cervical spine were studied. The mean age at the time of the operation was 8.9 years, and the patients had been followed for three days to forty-nine months. Complications related to the operation occurred in all patients. They included infection and dehiscence at the site of the wound, incomplete reduction of the atlanto-axial joint, instability of the adjacent motion segment, neurological sequelae, resorption of the autogenous bone graft, and death in the postoperative period. Resorption of the bone graft, which occurred in six of the patients, has not previously been reported in patients who have Down syndrome, to our knowledge. Several theoretical mechanisms for this complication are proposed. We recommend non-operative management for patients who have Down syndrome and atlanto-axial instability without neurological signs or symptoms. If the severity of symptoms necessitates a posterior arthrodesis, a high rate of complications must be anticipated.

Blood loss after total knee replacement. Effects of tourniquet release and continuous passive motion.

We prospectively studied the cases of 121 patients who were being operated on for insertion of a unilateral total knee prosthesis with cement, and we placed them randomly in four groups. In Group I, the tourniquet was inflated throughout the operative procedure, and we released it postoperatively after a compressive dressing had been applied; a splint was used postoperatively for three days. In Group II, the tourniquet remained inflated throughout the operation, but no splint was applied postoperatively, and continuous passive motion was started immediately in the recovery room. In Group III, the tourniquet was released intraoperatively, and hemostasis was achieved by cauterization; postoperatively, a compressive dressing was applied, and a splint was used for three days. In Group IV, the tourniquet was released intraoperatively, hemostasis was established, and then the tourniquet was reinflated; a compressive dressing was applied, and continuous passive motion was started immediately in the recovery room. Hemoglobin and hematocrit values were monitored in all patients. Blood loss in suction drainage was recorded, and the total blood loss was calculated. The results show that total knee arthroplasty is associated with major loss of blood (mean, 1518 milliliters). The calculated blood loss for Groups I, II, and III averaged 1443 milliliters, while that for Group IV averaged 1793 milliliters. Loss in suction drainage correlated with total estimated blood loss and averaged 511 milliliters. The magnitude of blood loss after total knee arthroplasty should be appreciated, and special attention should be paid to the availability of adequate fluid and blood products, preferably blood donated by the patient preoperatively.

Occipitocervical arthrodesis in children. A new technique and analysis of results.

A new wiring technique for occipitocervical arthrodesis was used in sixteen consecutive children between 1985 and 1992. The twelve boys and four girls had an average age of nine years and six months (range, two years and five months to nineteen years and three months) at the operation. The arthrodesis was performed between the occiput and the second cervical vertebra in ten patients and between the occiput and the third cervical vertebra in six. The instability was related to congenital anomalies (six patients), decompression for cervical stenosis (four patients), Down syndrome (three patients), trauma (one patient), resection of a tumor (one patient), and neurofibromatosis (one patient). Six patients needed a laminectomy for decompression because of cervical stenosis or for removal of a tumor. All of the patients were managed with an autogenous bone graft from the iliac crest and postoperative immobilization with a halo device. Fusion was achieved in fifteen of the sixteen patients. Complications developed in seven patients. The use of wire fixation, combined with the inherent stability of the bone-graft construct, allowed for removal of the halo device relatively early (range, six to twelve weeks), before the fusion was fully mature. No graft was displaced. All of the patients were followed at least until there was radiographic evidence of fusion (fifteen patients) or until a reoperation was performed (one patient). The average duration of follow-up was thirty-seven months (range, twelve to 108 months).

Serratus anterior paralysis in the young athlete.

Ten cases of isolated, complete paralysis of the serratus anterior muscle were diagnosed in young athletes during a three-year period. One patient had recurrent partial paralysis of the serratus anterior muscle, the first such case reported. From studies on cadavera and clinical observations, we concluded that paralysis of the serratus anterior muscle results from a traction injury to the long thoracic nerve of Bell. Since full recovery usually occurs in an average of nine months, surgical methods of treatment should be reserved for patients in whom function fails to return after a two-year period. Non-strenuous use of the involved extremity with avoidance of the precipitating activity, followed by exercises designed to maintain the range of motion of the shoulder and to increase the strength of associated muscles, is advocated for treatment of acute or repetitive injuries to the long thoracic nerve of Bell.

Computer tomography evaluation of Cotrel-Dubousset instrumentation in idiopathic scoliosis.

In 30 adolescent patients with 36 structural curves undergoing posterior spinal arthrodesis using Cotrel-Dubousset (CD) instrumentation, computer tomography (CT) was performed to evaluate the change in rotation and in the sagittal plane. The average preoperative Cobb angle was 51.7 degrees, and improved to 18.7 degrees postoperatively, or 64.9%. The angle of rotation of the apical vertebra relative to the anterior midline of the body (RAML) improved from 27.9 degrees preoperatively to 21.5 degrees postoperatively (23.9%). The angle of rotation relative to the sagittal plane (RAsag) improved from 15.2 degrees preoperatively to 13.4 degrees postoperatively (14.3%). The kyphotic angle increased an average of 10.6 degrees in the 14 patients whose preoperative angle was less than 25 degrees. As measured by CT, CD instrumentation improves both the rotational and sagittal plane deformities better than that reported for other systems.

Prevention of recurrent fetal loss caused by antiphospholipid syndrome.

Repeated fetal loss presents a challenge for both patients and health care professionals. Antiphospholipid syndrome (APS) may account for as much as 10% to 48% of recurrent fetal loss. Suggested pathophysiologic mechanisms of APS in fetal loss include the action of autoantibodies, the lupus anticoagulant, and anticardiolipin antibodies on the endothelial cells, which may lead to platelet aggregation, thrombosis, placental infarcts, and subsequently reduced oxygenation to the fetus. This study explores fetal loss caused by APS, its pathophysiologic features, treatment, and nursing implications. Heparin therapy is presented as a method to prevent intrauterine growth retardation and fetal death. The educational and psychosocial needs of patients receiving this therapy and necessary patient follow-up and coordination of services are reviewed.

Postoperative care of the total knee patient.

After total knee surgery the three most important problems are thromboembolic disease, disorders of wound healing, and inadequate range of motion. With the use of prophylactic anticoagulation, CPM, autologous blood replacement, good nutrition, and careful wound closure, most patients will have an uneventful postoperative course and reach the maximum potential from their knee arthroplasty.

Osteonecrosis of the knee.

We have described two entities of osteonecrosis-like syndromes about the knee. One involves the medial femoral condyle and may or may not be associated with radiolucent lesions and collapse of the femoral condyle. Treatment depends on identification of the size and location of the lesion. The other entity is an osteonecrosis-like lesion of the tibial plateau. It usually occurs medially and may not be associated with radiographic changes. However, increased uptake on a bone scan from the medial side of the knee, best noted on the lateral view, will identify these lesions. Once the condition is recognized, the patient should be treated conservatively until the clinical course is defined. It is important to recognize these clinical problems so that unnecessary surgery may be avoided.

Objective evaluation of peroneal response to sudden inversion stress.

The purposes of this paper are to describe an objective technique developed to assess the dynamic response of the peroneal muscles to a sudden inversion motion and to report the results obtained from testing injured and noninjured ankles. A platform was constructed to drop the ankle into a controlled degree of inversion while measuring the time to peroneal response and the angular rotation. Thirty volunteers were tested, 15 of whom had experienced a unilateral ankle sprain 3- 10 months prior to testing. Results show a trend toward delayed peroneal response and greater angular displacement at the time of peroneal response in injured ankles but analysis of variance showed no significant difference. The total angular displacement in the injured ankles was significantly greater. This objective technique could be used to evaluate treatment regimens and, by testing ankles soon after injury and serially, to evaluate readiness to return to activity. J Orthop Sports Phys Ther 1985;7(3):107-109.