Needle­based gastrocnemius lengthening: a novel ultrasound­guided noninvasive technique: part II-clinical results.

BACKGROUND: Isolated gastrocnemius contracture has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flatfoot, and metatarsalgia. Although many techniques are available for gastrocnemius recession, potential anesthetic, cosmetic, and wound-related complications can lead to patient dissatisfaction. Open and endoscopic recession techniques usually require epidural or general anesthesia, exsanguination of the lower extremities and stitches and can damage the sural nerve, which is not under the complete control of the surgeon at all stages of the procedure. The purpose of this study is to evaluate the clinical results of a surgical technique for gastrocnemius lengthening with a needle, as previously described in cadaver specimens. METHODS AND RESULTS: We performed a prospective study of ultrasound-guided gastrocnemius tendon lengthening in level II using a needle in 24 cases (19 patients) of gastrocnemius contracture. The study population comprised 12 males and 7 females. Mean age was 41 years (18-64). All but 5 recessions were bilateral and occurred simultaneously. The indication for the procedure was gastrocnemius contracture; although the patients also presented other conditions such as non-insertional Achilles tendinopathy in 6 patients (2 were bilateral), insertional Achilles calcifying enthesitis in 4 (1 was bilateral), metatarsalgia in 4, flexible flat foot in 1 and plantar fasciitis in 5 (2 were bilateral). The inclusion criteria were the failure of a previous conservative protocol, that the Silfverskiöld test was positive, and that the pathology suffered by the patient was within the indications for surgical lengthening of the patients and were described in the scientific literature. The exclusion criteria were that the inclusion criteria were not met, and patients with surgical risk ASA 3 or more and children. In these patients, although possible, it is preferable to perform the procedure in the operating room with monitoring, as well as in children since they could be agitated during the procedure at the office. We used the beveled tip of an Abbocath needle as a surgical scalpel. All patients underwent recession of the gastrocnemius tendon, as in an incomplete Strayer release. We evaluated pre- and postoperative dorsiflexion, outcomes, and procedural pain (based on a visual analog scale and the American Orthopedic Foot and Ankle Society scores), as well as potential complications. No damage was done to the sural bundle. RESULTS: Ankle dorsiflexion increased on average by 17.89°. The average postoperative visual analog score for pain before surgery was 5.78, 5.53 in the first week, 1.89 at 1 month, and 0.26 at 3 months, decreasing to 0.11 at 9 months. The mean postoperative American Orthopedic Foot and Ankle Society Ankle-Hindfoot score the average was 50.52 before surgery, 43.42 at 1 week, 72.37 at 1 month, 87.37 at 3 months, and 90.79 at 9 months. CONCLUSION: Ultrasound-guided needle lengthening of the gastrocnemius tendon is a novel, safe, and effective technique that enables the surgeon to check all the structures clearly, thus minimizing the risk of neurovascular damage. The results are encouraging, and the advantages of this approach include absence of a wound and no need for stitches. Recovery is fast and relatively painless. A specific advantage of ultrasound-guided needle lengthening of the gastrocnemius tendon is the fact that it can be performed in a specialist's office, with a very basic instrument set and local anesthesia, thus reducing expenses.

A novel closed technique for ultrasound-guided plantar fascia release with a needle: review of 107 cases with a minimum follow-up of 24 months.

BACKGROUND: This study aims to analyze the clinical outcome of a new ultrasound-guided surgery for partial plantar fasciotomy performed with a needle for treatment of plantar fasciitis. METHODS: We performed a retrospective review of 107 patients diagnosed with plantar fasciitis who underwent ultrasound-guided release of the plantar fascia. The series included 62 males (57.9%) and 45 females (42.1%) treated between April 2014 and February 2018, with a mean follow-up of 21.05 ± 10.96 months (7-66) and a minimum follow-up of 24 months. The mean age was 48.10 ± 10.27 years (27-72). Clinical assessments and ultrasound examination were carried out before treatment, after 1 week, and then after 1, 3, 12, and 24 months. The clinical assessment was based on a visual analog scale and the Foot and Ankle Disability Index. RESULTS: Heel pain improved in 92.5% (99) of patients, but not in 7.4% (8 patients). In the group of patients whose heel pain improved, 9 experienced overload on the lateral column and dorsum of the foot, which improved with the use of plantar orthoses and a rehabilitation program. We recorded no nerve complications (e.g., paresthesia), vascular injuries, or wound-related problems. CONCLUSION: Ultrasound-guided partial plantar fasciotomy with a needle is safe, since structures are under direct visualization of the surgeon and the risk of damage is minimal. Stitches are not necessary, and recovery is fast. Consequently, costs are low, and the patient can return to work quickly. This technique may represent a valid option for treatment of plantar fasciitis.

Results of ultrasound-guided release of tarsal tunnel syndrome: a review of 81 cases with a minimum follow-up of 18 months.

BACKGROUND: This study aims to analyse the clinical results of ultrasound-guided surgery for the decompression of the tibial nerve, including its distal medial and lateral branches, to treat tarsal tunnel syndrome. These structures are the complete flexor retinaculum and the deep fascia of the abductor hallucis muscle, including individualised release of the medial and lateral plantar nerve tunnels. METHOD: This is a retrospective review of 81 patients (36 men and 45 women) with an average age of 41 years old (32-62) and an average clinical course of 31 months (8-96) compatible with idiopathic tarsal tunnel syndrome, who underwent ultrasound-guided decompression of the proximal and distal tarsal tunnel between February 2015 and November 2017 (both months included), with a minimum follow-up of 18 months. RESULTS: Based on the Takakura et al. scale for the 81 patients, 76.54% obtained excellent results, 13.58% good results, and 9.87% poor results. The patients with the longest course of symptoms displayed the worst results. CONCLUSION: Although 9% of patients did not improve, ultrasound-guided tarsal tunnel release might be a viable alternative to conventional open approaches.

Risk factors in iatrogenic spinal cord injury.

STUDY DESIGN: In the last years, there has been a change in the aetiology of spinal cord injury. There has been an increase in the number of elderly patients with spinal cord injuries caused by diseases or medical procedures. OBJECTIVE: The aim of this study is to investigate the frequency of the occurrence of iatrogenic spinal cord injury in our unit. The secondary aim is to study what variables can be associated with a higher risk of iatrogenesis. METHODS: A retrospective, descriptive, observational study of patients with acute spinal cord injury admitted from June 2009 to May 2014 was conducted. The information collected included the patient age, aetiology, neurological level and grade of injury when admitted and when discharged, cardiovascular risk factors, a previous history of depression and any prior treatment with anticoagulant or antiplatelet drugs. We applied a logistic regression. The grade of statistical significance was established as P<0.05. RESULTS: In total, 265 patients were included. In 48 of the cases, the cause was iatrogenic (18.18%±4.6% IC). The most frequent level of injury was the thoracic level (48%). The main aetiology of spinal cord injury caused by iatrogenesis was surgery for degenerative spine disease, in patients under the age of 30 were treated with intrathecal chemotherapy. CONCLUSIONS: Iatrogenic spinal cord injury is a frequent complication. A statistically significant association between a patient history of depression and iatrogenic spinal cord injury was found as well as with anticoagulant and antiplatelet drug use prior to iatrogenic spinal cord injury.

Antioxidant activity of N-acetylcysteine, flavonoids and alpha-tocopherol on endometrial cells in culture.

An appropriate local environment is necessary for successful implantation. Oxidative stress is implicated in the pathogenesis of several pathologies, and may contribute to early pregnancy failure. Antioxidant therapies have been studied in infertility. In this study, we have assessed the antioxidant activity of N-acetylcysteine (NAC), flavonoids (quercetin, catechin) and alpha-tocopherol in an oxidative model of endometrial cells (RL95). Endometrial cells were incubated at several hydrogen peroxide concentrations. Antioxidant effects of NAC (15 mM), quercetin (150 microM), catechin (150 microM) and alpha-tocopherol included in liposomes (1.6 microg) were assessed by measuring cell viability by the MTT assay. Alpha-tocopherol-liposomes taken up by endometrial cells were assessed by HPLC. All liposomes used were able to introduce alpha-tocopherol into cells. The antioxidant effect of NAC and quercetin improved the viability of oxidised cells, and this effect was observed when the oxidant and antioxidant were coincubated. No viability change occurred when the antioxidant was added before or after the oxidant. The antioxidant effect of NAC was better than that of quercetin. When catechin or alpha-tocopherol were used in the same conditions, no antioxidant effect was detected in cells in culture. These results demonstrate that NAC and quercetin are good H2O2 scavengers.

The presence of antibodies to oxidative modified proteins in serum from polycystic ovary syndrome patients.

Polycystic ovary syndrome (PCOS) affects 5-10% of women of reproductive age. Free radicals, as a product of oxidative stress, impair cells and tissue properties related to human fertility. These free radicals, together with the oxidized molecules, may have a cytotoxic or deleterious effects on sperm and oocytes, on early embryo development or on the endometrium. Aldehyde-modified proteins are highly immunogenic and circulating autoantibodies to new epitopes, such as malondialdehyde (MDA), may affect the reproductive system. Autoantibodies or elevated reactive oxygen species (ROS) in serum are often associated with inflammatory response. The purpose of this work is to investigate whether PCOS women show increased levels of oxidized proteins (protein-MDA) and anti-endometrial antibodies (AEA) in their sera, compared with control patients, and to determine whether AEA specificity is related to oxidized protein derivatives. Sera from 31 women [10 patients with PCOS (PCOS group) and 21 women with male factor of infertility (control group)] were chosen from patients attending for infertility. Anti-endometrial antibodies were determined by enzyme-linked immunosorbent assay (ELISA) with an endometrial cell line (RL-95). Antibodies against MDA modified human serum albumin (HSA-MDA) were also determined by ELISA. Oxidized proteins (protein-MDA) in serum were determined by a colorimetric assay. Patients with PCOS have significantly higher levels of AEA and anti-HSA-MDA, as well as oxidized proteins (protein-MDA) in serum than control patients. For the first time, we describe an autoimmune response in PCOS patients, in terms of AEA. The evidence of protein-MDA in the serum of these patients, together with the increased antibody reactivity to MDA-modified proteins (HSA-MDA) in vitro, supports the conclusion that oxidative stress may be one of the important causes for abnormal endometrial environment with poor embryo receptivity in PCOS patients.

Expression of complement regulatory proteins [membrane cofactor protein (CD46), decay accelerating factor (CD55), and protectin (CD59)] in endometrial stressed cells.

In the female reproductive tract, the complement system represents a defense mechanism that can act directly against pathogens and cells, and mediates inflammatory response. Endometrial cells are protected from autologous complement attack by membrane-bound complement regulatory proteins (CRPs) that prevent complement activation: membrane cofactor protein (CD46), decay accelerating factor (CD55), and protectin (CD59). In this work we show that all CRPs were overexpressed after LPS exposure. Maximal stimulatory effect was detected after 6h, and was declining after 12h, reaching control levels in 24h. CD59 was the protein showing the more prominent effect. There seems to be a slight increase of CRP expression in the endometrium of sterile patients that have anti-endometrial antibodies (AEA) in their serum. Our results suggest that under stress, the high expression of CRPs (CD46, CD55, and CD59) could protect endometrial injured cells against complement mediated lysis. The survival of these cells with some biochemical modifications would enable autoimmune response.

Autoimmune response in women with endometriosis.

PROBLEM: The aim of this study was to investigate the humoral immune response to the female reproductive tissues associated with endometriosis (grades I-III) (n = 52), compared with a group of healthy fertile women (n = 6). METHOD OF STUDY: An ELISA with cultured endometrial cell lines in monolayer was used to determine the presence of anti-endometrial antibodies (AEA). For anti-zona pellucida antibodies (AZPA) assessment a conventional ELISA was employed. The presence of antibodies to human sperm (ASA) was performed by the tray agglutination test (TAT). RESULTS: Endometriosis grade III was associated with AEA in serum in the 45.4% of patients. The presence of AEA in serum is correlated to endometriosis severity. The 8.7% of women with endometriosis showed ASA, and the 10.9% of them were positive for AZPA. Antibodies specific for endometrial cells do not show reaction to any gamete antigen (sperm or oocyte), suggesting that they are not cross reactive. CONCLUSIONS: Severity of endometriosis is correlated with high titers of AEA.

Phosphorylation of Shc proteins in human sperm in response to capacitation and progesterone treatment.

Several authors have demonstrated the involvement of tyrosine kinases during sperm capacitation and acrosome reaction. Shc proteins (p46Shc, p52Shc, and p66Shc) are cytoplasmic substrates of activated tyrosine kinases and are widely expressed in mammalian somatic tissues. Experiments were designed to demonstrate the presence of Shc in spermatozoa and to study its involvement in the signal transduction events leading to acrosome reaction. Anti-Shc antibodies strongly reacted with the acrosomal region of methanol-fixed human sperm. Only one Shc isoform (p52Shc) was detected on Western blot. To study the degree of phosphorylation of Shc during capacitation and acrosome reaction, sperm samples were divided into two groups: noncapacitated and capacitated/progesterone treated. Lysates from both groups were immunoprecipitated with anti-phosphotyrosine antibodies and the precipitated (i.e., phosphorylated) proteins were tested with anti-Shc antibodies. The intensity of p52Shc was clearly increased in capacitated/progesterone-stimulated cells.

Monoclonal antibodies against boar sperm zona pellucida-binding protein AWN-1. Characterization of a continuous antigenic determinant and immunolocalization of AWN epitopes in inseminated sows.

Boar spermadhesin AWN-1 is a sperm surface-associated 14.7-kDa lectin and a major protein of porcine seminal plasma. AWN-1 binds to beta-galactosides and to porcine zona pellucida glycoproteins, suggesting that this protein might play a role in the primary binding of spermatozoa to the egg's external glycoprotein matrix. We have produced a collection of murine monoclonal antibodies against purified AWN-1. Five monoclonal antibodies recognized sequential antigenic determinants. All these epitopes were located at the C-terminal region of AWN-1 (residues 109-123) by competitive ELISA using overlapping synthetic peptides that cover the complete 133 amino acid sequence of the lectin. In a structural model of spermadhesin AWN-1, the polypeptide stretch 109-123 is fully solvent-exposed, providing a reasonable explanation for its high immunogenicity. In addition to epitope mapping, we have employed anti-AWN monoclonal antibodies for immunolocalization of the protein in the genital tract of inseminated sows. Clusters of AWN epitopes were occasionally found attached to the epithelium of the uterotubal junction and the adjacent lower isthmus. However, neither AWN-1 nor other seminal plasma proteins were found in the isthmic fluid collected 10-26 h after insemination. These results suggest that the whole amount of seminal plasma proteins are absorbed by the epithelium of the female genital tract, supporting the claim that removal of seminal plasma components from spermatozoa might be a major event in both in vitro and in vivo sperm capacitation.

Anti-endometrial autoantibodies in women with a diagnosis of infertility.

PROBLEM: The purpose of this study was to investigate the frequency of anti-endometrial antibodies (AEA) in infertile women. METHOD OF STUDY: Sera from fertile women (n = 6), and from patients with ovulatory dysfunction (n = 11), tubal obstruction (n = 9) and unexplained infertility (n = 5) were investigated for the presence of anti-endometrial membrane antibodies. We used two human endometrial cancer cell lines and human endometrial cells from gynecological biopsies as an antigenic source for analysis. The immunoenzymatic assay (ELISA) was performed with cultured endometrial cells in monolayers. Immunoblot analysis was performed with these two cell lines. RESULTS: A good correlation between the response with each cell line and with human endometrial cells was obtained, indicating that the antigens analyzed were probably similar. Endometrial antibodies were detectable in a high percentage of women with tubal obstruction (77.8 and 66.7%, respectively) and ovulatory dysfunction (54.5 and 45.5%, respectively). Unexplained infertility showed anti-endometrial immunological response (40 and 60%, respectively). Some endometrial antigens in infertile women are the target for autoimmune response. The serum from a patient with tubal obstruction and ovulatory dysfunction showed two antigens by immunoblot, with molecular weights of 97 and 50 kDa. CONCLUSION: The presence of anti-endometrial antibodies, detected by ELISA, is associated with infertility, mainly with ovulatory dysfunction and tubal obstruction. Some endometrial antigens may be involved in these two pathologies.

Cloning and characterization of CSP37, a novel gene encoding a putative membrane protein of Candida albicans.

In the course of an analysis of the functions and assembly of the cell wall of Candida albicans, we have cloned and characterized a gene, which we designated CSP37 (cell surface protein), encoding a 37-kDa polypeptide which is a membrane-associated protein. The gene was isolated by immunological screening of a DNA library constructed from mycelial cells with a polyclonal serum raised against cell walls of this morphology. Analysis of the nucleotide sequence of a corresponding genomic DNA fragment revealed a single open reading frame which encodes a predicted protein of 321 amino acids with no significant homology to others in the databases. Disruption of the CSP37 gene by the method described by Fonzi and Irwin (Genetics 134:717-728, 1993) eliminated expression of the Csp37 protein. The mutant strains showed no apparent defect in cell viability, growth, or cell wall assembly but displayed attenuated virulence in systemic infections induced in mice and reduced the ability to adhere to polystyrene.

Characterization of monoclonal antibodies specific for human sperm: effect of CRL-10 on acrosome reaction.

Monoclonal antibodies to human sperm were obtained from hyperimmunized BALB/c mouse spleen cells fused with myeloma NS-1 cells. Each antibody recognized definite regions in fresh unfixed sperm: equatorial region, acrosome, postacrosome, midpiece, tail. All the antibodies were specific for sperm. We selected CRL-10 monoclonal antibody, specific for acrosome, for a detailed study. The expression of the CRL-10 antibody-bound antigen was detected in other mammalian species. When CRL-10 antibody was added prior to sperm incubation in a capacitating medium, promotion of the acrosome reaction was observed.