A Modification of the Dunn Osteotomy With Preservation of the Ligamentum Teres.

BACKGROUND: We aimed to determine if a modified Dunn osteotomy could be safely performed without surgical dislocation and consequent preservation of the ligamentum teres. METHODS: All patients undergoing a modified Dunn osteotomy for a slipped capital femoral epiphysis over an 8-year period were included in this study, and all had a severe slip with an open physis. RESULTS: The modified Dunn procedure was performed on 34 hips in 34 patients. The mean age was 13.1 years (range, 11 to 16 y) with a mean follow-up time of 54 months (range, 15 to 102 mo). All slips were severe (grade 3) with a mean slip angle of 73.2 degrees (range, 60 to 90 degrees). Nineteen slips were stable and 15 were unstable. Of the unstable slips, the average time from initial presentation to the emergency department until surgery was 9.4 days (range, 2 to 42 d). Excluding 1 patient who developed complete collapse of the femoral head (NAHS 56), the average Nonarthritic Hip score was 98 (range, 93.7 to 100). Four (11.8%) patients developed avascular necrosis of the femoral head, of which 3 were unstable slips. CONCLUSIONS: A modified Dunn osteotomy with preservation of the ligamentum teres allows an excellent restoration of the anatomic alignment of the femoral head and neck. Rates of AVN are not increased compared with other techniques of subcapital osteotomy but this complication cannot be eliminated particularly in patients with unstable slips. LEVEL OF EVIDENCE: Level III.

Lower Extremity Deformity Management in MPS IVA, Morquio-Brailsford Syndrome: Preliminary Report of Hemiepiphysiodesis Correction of Genu Valgum.

BACKGROUND: Morquio-Brailsford syndrome or mucopolysaccharidosis type IV-A (MPS IV-A) is an inherited metabolic disease in which skeletal deformities can be extreme. An international registry has shown that 46% of patients are unable to walk 200 m and 30% use a wheelchair. Lower limb surgery is performed to restore alignment with the expectation of maintaining mobility. We are, however, not aware of reports correlating function with alignment. This study assesses the role of orthopaedic intervention with reference to anatomic and functional outcome in MPS IV-A: specifically hemiepiphysiodesis correction of genu valgum. METHODS: Interrogation of the MPS patient database identified 63 patients. Patient demographic and radiographic data were collected along with information on deformity, correction, mobility, and genotype. Genu valgum was assessed by intermalleolar distance and mobility by a standardized 6-minute walk test. Sequential hip anatomy was assessed radiographically. RESULTS: Twenty-six surgical hemiepiphysiodesis episodes were performed on 23 patients. There were no cases of implant failure, loosening, or infection. The average intermalleolar distance reduction was 6.12 cm (paired t test, P=0.0001) (95% confidence interval, 7.6-4.7 cm) and the mean change in 6-minute walk test was +69.5 m (P=0.0339). There was no correlation between hip subluxation/dislocation and mobility (Fisher exact test, P=1.000), although hip parameters deteriorated over time. Three patients required repeat 8-plate insertion and 1 a femoral osteotomy. CONCLUSIONS: Eight-plate hemiepiphysiodesis correction of genu valgum in MPS IV-A is an effective treatment with low complication rates. The insult of surgery is minimal compared with that of osteotomy which can reduce mobility further. Our outcomes suggest that mobility is maintained or improved even in severe genotypes where mobility typically worsens. We have found hip pathology to be less debilitating, but further studies are needed to assess the effect of genu valgum correction upon femoral head subluxation and collapse.We suggest hemiepiphysiodesis should be considered as part of the treatment strategy for limb alignment in MPS IV-A patients, depending on remaining growth, mobility status, and genotype. LEVEL OF EVIDENCE: Level IV-therapeutic case series.

[Problems in microbial safety of advanced therapy medicinal products. Squaring the circle]. / Probleme der mikrobiellen Sicherheit bei neuartigen Therapien. Die Quadratur des Kreises.

Today, sterility of parenteral drugs is practically guaranteed. Well-defined procedures in the pharmaceutical industry enable effective protection against contamination by bacteria and fungi. In contrast, problems regarding microbial safety of advanced therapy medicinal products (ATMPs), especially of cell therapeutics, are at best only partially solved. The latter should be understood as a challenge for manufacturers, regulators, and physicians. Many of the manufacturing principles mentioned above are not applicable in production of cell therapeutics. Sterility of source materials cannot be guaranteed and the hitherto known procedures for sterilization are, as a rule, not feasible. Thus, the sterility of the final product cannot be guaranteed. Considering the extremely short shelf life of many cell therapeutics, sometimes only a few hours, the results from established methods for sterility testing are often available too late. Furthermore, the sterility of a test sample does not indicate sterility of the whole product. In most cases, conventional methods for pyrogen testing are not applicable for ATMPs. This paper demonstrates relevant limitations regarding microbial safety and pyrogenicity. Possibilities to overcome these problems are discussed and some novel solutions are proposed.

Is acetabular morphology related to trochlear dysplasia?

PURPOSE: To evaluate the correlation between trochlear dysplasia and acetabular coverage. MATERIALS AND METHODS: 109 retrospective CT studies referred from the young adult knee clinic were independently reviewed by two observers. Anterior acetabular (AASA) and posterior acetabular (PASA) sector angles were calculated bilaterally on axial CT. Trochlear dysplasia was graded using the Dejour classification (A-D). ANOVA test was used. RESULTS: Dejour types A, B and D trochlear dysplasia were associated with a significantly increased AASA (P value = 0.0011). CONCLUSION: Our results demonstrate a significant relationship between trochlear dysplasia and anterior acetabular coverage, as measured by AASA.

Combined two-centre experience of single-entry telescopic rods identifies characteristic modes of failure.

AIMS: The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant. METHODS: In total, 34 children with a mean age of five years (1 to 14) with severe OI have undergone rodding of 72 lower limb long bones (27 tibial, 45 femoral) for recurrent fractures with progressive deformity despite optimized bone health and bisphosphonate therapy. Data were collected prospectively, with 1.5 to 11 years follow-up. RESULTS: A total of 24 patients (33%) required exchange of implants (14 femora and ten tibiae) including 11 rods bending with refracture. Four (5%) required reoperation with implant retention. Loss of proximal fixation in the femur and distal fixation in the tibia were common. Four patients developed coxa vara requiring surgical correction. In total, 13 patients experienced further fractures without rod bending; eight required implant revision. There was one deep infection. The five-year survival rate, with rod revision as the endpoint, was 63% (95% confidence interval (CI) 44% to 77%) for femoral rods, with a mean age at implantation of 4.8 years (1.3 to 14.8), and 64% (95% CI 36% to 82%) for tibial rods, with a mean age at implantation of 5.2 years (2.0 to 13.8). CONCLUSION: FD rods are easier to implant but do not improve on the revision rates reported for second generation T-piece rods. Proximal femoral fixation is problematic in younger children with a partially ossified greater trochanter. Distal tibial fixation typically fails after two years. Future generation implants should address proximal femoral and distal tibial fixation to avoid the majority of complications in this series. Cite this article: Bone Joint J 2020;102-B(8):1048-1055.

Residues of total mercury and methylmercuric salts in lake trout as a function of age.

An analysis of the concentrations of total mercury and methylmercuric salts in lake trout of precisely known ages from 1 to 12 years has been carried out. The concentrations of both total mercury and methylmercury increased with the age of the fish. The proportion of methylmercury to total mercury also increased with age.

Polychlorinated biphenyl residues: accumulation in Cayuga Lake trout with age.

The concentration of polychlorinated biphenyls was shown to progressively increase with maturity in a series of lake trout. The presence of these compounds was determined by column chromatographic isolation, specific detector gas chromatography and mass spectrometry. The relation between fish age and the concentration of polychlorinated biphenyls was highly significant.

Selenium in fly ash.

Selenium, at concentrations exceeding 200 parts per million (ppm) (dry weight), has been found in white sweet clover voluntarily growing on beds of fly ash in central New York State. Guinea pigs fed such clover concentrated selenium in their tissues. The contents of the honey stomachs of bees foraging on this seleniferous clover contained negligible selenium. Mature vegetables cultured on 10 percent (by weight) fly ash-amended soil absorbed up to 1 ppm of selenium. Fly ashes from 21 states contained total selenium contents ranging from 1.2 to 16.5 ppm. Cabbage grown on soil containing 10 percent (by weight) of these fly ashes absorbed selenium (up to 3.7 ppm) in direct proportion (correlation coefficient r = .89) to the selenium concentration in the respective fly ash. Water, aquatic weeds, algae, dragonfly nymphs, polliwogs, and tissues of bullheads and muskrats from a fly ash-contaminated pond contained concentrations of selenium markedly elevated over those of controls.

Eggshell thinning in Japanese quail fed mercuric chloride.

The eggs produced by developing Japanese quail (Coturnix coturnix japonica) fed 1 to 8 parts of mercury per million as mercuric chloride for 10 weeks have thinned shells. Total amounts of mercury in tissues were quite proportional to the dosage and were higher in males than in females. Methylation of mercury was not observed.

Application of Bayesian statistics to estimate nitrous oxide emission factors of three nitrogen fertilisers on UK grasslands.

Trapezoidal integration by linear interpolation of data points is by far the most commonly used method of cumulative flux calculations of nitrous oxide (N2O) in studies that use flux chambers; however, this method is incapable of providing accurate uncertainty estimates. A Bayesian approach was used to calculate N2O emission factors (EFs) and their associated uncertainties from flux chamber measurements made after the application of nitrogen fertilisers, in the form of ammonium nitrate (AN), urea (Ur) and urea treated with Agrotain® urease inhibitor (UI) at four grassland sites in the UK. The comparison between the cumulative fluxes estimated using the Bayesian and linear interpolation methods were broadly similar (R2 = 0.79); however, the Bayesian method was capable of providing realistic uncertainties when a limited number of data points is available. The study reports mean EF values (and 95% confidence intervals) of 0.60 ±â€¯0.63, 0.29 ±â€¯0.22 and 0.26 ±â€¯0.17% of applied N emitted as N2O for the AN, Ur and UI treatments, respectively. There was no significant difference between N2O emissions from the Ur and UI treatments. In the case of the automatic chamber data collected at one site in this study, the data did not fit the log-normal model, implying that more complex models may be needed, particularly for measurement data with high temporal resolution.

The management of open tibial fractures in children: a retrospective case series of eight years' experience of 61 cases at a paediatric specialist centre.

AIMS: Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. PATIENTS AND METHODS: A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. RESULTS: There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. CONCLUSION: Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544-53.

Flexible intramedullary nails for unstable fractures of the tibia in children. An eight-year experience.

Flexible intramedullary nailing is gaining popularity as an effective method of treating long-bone fractures in children. We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 1997 and May 2005. All were followed up for at least two months after the removal of the nails. Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome. We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children.

Financial justification for routine ultrasound screening of the neonatal hip.

We have analysed the patterns of management of developmental dysplasia of the hip (DDH) in Coventry over a period of 20 years during which three different screening policies were used. From 1976 to the end of 1985 we relied on clinical examination alone. The mean surgical cost for the treatment of DDH during this period was Pound Sterling 5110 per 1000 live births. This was reduced to Pound Sterling 3811 after the introduction of ultrasound for infants with known risk factors. Since June 1989 we have routinely scanned all infants at birth with a mean surgical cost of Pound Sterling 468 per 1000 live births. This reduction in cost is a result of the earlier detection of DDH with fewer children requiring surgery. In those who do, fewer and less invasive procedures are needed. The overall rate of treatment has not increased and regular review of patients managed in a Pavlik harness has allowed us to avoid the complication of avascular necrosis. When we add the cost of running the screening programme to the expense of treating the condition, the overall cost for the management of DDH is comparable for the different screening policies.

Absence of cadmium in the blood of horses fed oats grown on municipal sludge-amended soil.

Effluents from a number of industries which are typically treated in municipal sewage plants result in cadmium-containing sludge. Disposal of such sewage sludge by application to agricultural land can result in uptake of cadmium by crops. In this study, oats were grown on soils which had been amended with sewage sludge from Syracuse, New York. The cadmium concentration in the sludge-grown oats was 1.79 ppm dry weight. Horses were fed the sludge-grown oats for 6 weeks during which time blood samples were taken for the determination of cadmium. No significant differences (p greater than 0.05) were found in the concentration of cadmium in the blood of the horses consuming the oats compared with that in the blood before feeding began (control). The well-known efficient accumulation of renal cadmium by horses may account for a lack of significantly increased cadmium in blood during the feeding period.

Cadmium deposition and hepatic microsomal activity in mice fed Swiss chard grown on municipal incinerator refuse ash.

Incineration of municipal solid waste results in the production of millions of tons of ash that may be typically high in heavy metals such as cadmium. Disposal of such ash in landfills capped with soil could lead to absorption of such metals by plants and deposition in foraging animal tissues. In this study, weanling, male mice were fed swiss chard that was grown on soil amended with 10% w/w municipal incinerator refuse ash. Cadmium was taken up by the swiss chard (8.15 ppm, dry wt). The mice fed diets containing 25% of ash-grown chard showed mean kidney and liver concentrations of cadmium (ppm, dry wt), respectively, of 2.80 +/- 0.30 and 0.45 +/- 0.03. Control mice fed soil-grown chard showed significantly lower kidney and liver concentrations of cadmium, i.e. 0.39 +/- 0.02 and 0.05 +/- 0.00 ppm. Since refuse incinerator ashes may contain various organic toxicants that can be hepatic microsomal inducers, the relative liver weights and hepatic microsomal aminopyrine N-demethylase and p-nitroanisole O-demethylase activities of mice fed control or ash-grown chard were measured. No consistent increases in these latter parameters were found in the ash-grown chard fed mice as compared with the control animals.

Toxicologic studies with swine fed corn grown on municipal sewage sludge-amended soil.

Over a 3-yr period 336 MT/ha of dried sewage sludge, from a municipal waste treatment plant, was applied in liquid form to land subsequently used to grow corn. The sludge contained 115 mg Cd, 4,200 mg Zn and 538 mg Ni/kg dry matter and comprised the solids remaining after treatment of the waste waters of approximately 260 industries as well as domestic users. Corn grain harvested from the plot amended with sewage sludge (SA corn) or corn grown on a plot without sludge addition (control corn) was fed to a total of 56 pigs to determine the effect on growth performance and parameters indicative of toxicity. Each treatment consisted of seven pens of four pigs each with an average initial weight of 17.6 kg. The growth trial was terminated when pigs weighed approximately 90 kg. No differences were observed between treatment groups for average daily gain, feed: gain ratio or daily feed intake. Higher (P less than .01) concentrations of Cd, Ni and Zn were found in SA corn compared with the control corn. This resulted in higher (P less than .01) concentrations of Cd in kidney and liver and Ni in kidney of pigs fed SA corn as compared with pigs fed control corn. No significant differences were observed in Cd or Ni concentrations in muscle or in hepatic microsomal mixed-function oxidase (MFO) activity and liver:body weight ratios, which is indicative of the absence or low levels of organic toxicants in SA corn. In addition, no significant treatment effects were observed when corn, feces and urine samples were evaluated for the presence of mutagenic substances. Histopathologic analysis of various tissues for lesions demonstrated that pigs fed SA corn were not adversely affected.

Toxicologic studies with lambs fed sugar beets grown on municipal sludge-amended soil: lowered relative hemoglobin in red blood cells and mutagens in blood and excreta.

Sugar beets grown on municipal sludge-amended soil were fed to growing lambs for 66 days. The relative hemoglobin content was significantly lower (P less than 0.05) in the lambs fed the sludge-grown sugar beets. The concentration of direct-acting mutagens was significantly higher (P less than 0.05) than controls in blood and urine of the lambs fed the sludge-grown beets. Cadmium concentration was higher, but not significantly (P greater than 0.05) in the livers and kidneys of the lambs fed the sludge-grown beets as compared with controls. Significant differences between treatment groups were not observed in active or passive K+ influxes in RBC; in the activity of hepatic microsomal aniline hydroxylase in p-nitroanisole-O-demethylase, aminopyrene-N-demethylase, or arylhydrocarbon hydroxylase; in tissue ultrastructure of kidney, liver, or muscle as examined by electron microscopy; or in carcass weight, dressing percentage, quality, or yield grade.

Multielement residues in tissues of guinea pigs fed sweet clover grown on fly ash.

Yellow sweet clover (Melilotus officinalis) was harvested from fly ash dumped in a landfill site at Lansing, NY. This clover was chopped, dried, and formulated at 45% into an otherwise purified diet and fed to six guinea pigs for 90 days. Control sweet clover was harvested from gravelly subsoil and processed and fed to another group of guinea pigs for the same period. Samples of fly ash, gravelly subsoil, sweet clover, liver, kidneys, and left-rear gastrocnemius muscle of all guinea pigs were freeze-dried and analyzed for 35 elements by neutron activation analysis. The fly ash contained 28 elements at higher levels than the gravelly subsoil, while the clover harvested from fly ash contained 19 elements in increased amounts over those in the clover harvested from the gravel soil. Growth rate of both groups of guinea pigs was similar. Rubidium and selenium were present at higher levels in the tissues of guinea pigs fed the fly ash clover.

Study of guinea pigs fed Swiss chard grown on municipal sludge-amended soil. Multi-element content of tissues.

Swiss chard, field-grown on soil amended with 100 dry tons per acre of municipal sewage sludge from Washington, DC, was fed to guinea pigs for 28 days. Control animals were fed Swiss chard grown on unfortified soi. Forty-one elements were determined in the sludge, the plant material, and liver, kidney, muscle, adrenal, and spleen tissues by neutron activation and other methods. Elevated concentrations of several elements found in the Swiss chard grown on the sludge-soil mixture also appeared at higher levels in certain of the animal tissues. These included antimony in adrenal, cadmium in kidney, manganese in liver tissues, and tin in several tissues. The animals showed no observable toxicological effects.