High-energy extracorporeal shock wave treatment of nonunions.

Forty-three consecutive patients who did not have healing of tibial or femoral diaphyseal and metaphyseal fractures and osteotomies for at least 9 months after injury or surgery were examined prospectively for use of high-energy extracorporeal shock waves. Former treatment modalities (cast, external fixator, plate osteosynthesis, limitation of weightbearing) remained unchanged. In all cases a 99mTechnetium dicarboxyphosphonate regional two-phase bone scintigraphy was performed before one treatment with 3,000 impulses of an energy flux density of 0.6 mJ/mm2. Radiologic and clinical followups were done at 4-week intervals starting 8 weeks after shock wave treatment. The success criterion was bridging of all four cortices in the anteroposterior and lateral radiographic views, in oblique views, or by conventional tomography. An independent observer described bony consolidation in 31 of 43 cases (72%) after an average of 4 months (range, 2-7 months). Twenty-nine of 35 (82.9%) patients with a positive bone scan had healing of the pseudarthrosis compared with two of eight (25%) patients with a negative bone scan. Six of these eight patients with negative scans were heavy smokers. No complications were observed. High-energy shock wave therapy seemed to be an effective noninvasive tool for stimulation of bone healing in properly selected patients with a diaphyseal or metaphyseal nonunion of the femur or tibia. Additional controlled studies are mandatory.

Ultrasonography performed by primary care residents for abdominal aortic aneurysm screening.

A prospective pilot study was undertaken to assess a protocol to educate primary care residents in how to personally perform ultrasonography for abdominal aortic aneurysm screening. Resident exams were proctored by a primary care physician trained in ultrasonography and were scored on the level of competence in doing the examination. Patients had ultrasound performed by a resident, followed by repeat examination by the vascular lab. Primary care resident abdominal aortic imaging was achieved in 79 of 80 attempts. Four abdominal aortic aneurysms were identified. There were 75 normal examinations; resident ultrasonography results were consistent with the results of the vascular lab. Ten residents achieved an abdominal aortic ultrasound-independent competence level after an average of 3.4 proctored exams. The main outcome of this study is that a primary care resident, with minimal training in ultrasonography imaging, is able to rapidly learn the technique of ultrasonography imaging of the abdominal aorta.

[The effect of various nucleotomy techniques on biomechanical properties of the intervertebral disk]. / Der Einfluss verschiedener Nucleotomietechniken auf die biomechanischen Eigenschaften der Bandscheibe.

AIM OF THE STUDY: The purpose of the present investigation was to determine the significance of the technique of nucleotomy for the biomechanical properties of the intervertebral disc. METHODS: From 29 human cadavers the lumbar-vertebral segment L2/3 was taken. The laminae were removed and the segment was tested by an mechanical testing device. Measurements were taken under physiological loads in flexion/extension, lateral bending and rotation direction. There after nucleotomy was simulated by four different procedures: perforation of the anulus with a diameter of 3 mm, rectangular excision (1 x 1 cm) of the anulus, discotomy with 3 g and 6 g nucleus pulposus. In each step the measurement was repeated. RESULTS: The size of the defect in the anulus fibrosus did not have significant influence on the stiffness of the disc. There was a significant relation between quantity of removed disc material and flexibility of the motion segment. CONCLUSION: The quantity of removed nucleus pulposus plays a crucial role in the segmental mobility whereas the size of the approach in the anulus fibrosus, f.e. endoscopic with a hole diameter of 3 mm or conventionally with a rectangular defect of 1 x 1 cm, did not influence mobility.

[Proximal fixation of hip endoprostheses with porous surface: results of 6 years]. / Proximale Verankerung von Hüft-Endoprothesen mit poröser Oberfläche: 6-Jahres-Ergebnisse.

PROBLEM: The anatomically shaped pcl (ESKA) total hip replacement has a porous coating of the proximal stem and the cup to allow for bony ingrowth. The tip of the stem is polished. METHOD: We report the results of 96 THR 6.2 years (5.25-6.7) after implantation. RESULTS: There were no revisions during this period. One stem showed radiographic loosening at follow-up. There was stress-shielding in 9.4% in contrast to the concept of proximal fixation. Thigh-pain was found in 9.4%. One patient demonstrated disabling thigh-pain despite radiologic bony ingrowth. By drilling the femur distal to the tip of the stem a remarkable relief was achieved. CONCLUSION: Despite numerous cases of stress-shielding (9.4%), bony ingrowth occurs in 97%. The tcl-THR performs sufficiently after 6 years of implantation.

[Comparison of the prognostic value of the Catterall and Herring classification in patients with Perthes disease]. / Vergleich der prognostischen Aussagefähigkeit der Catterall- und Herring-Klassifikation bei Patienten mit Morbus Perthes.

QUESTION: Investigation of the predictive value of the Catterall- as compared to the Herring-classification in patients with Perthes disease. METHOD: A radiological follow-up study including 53 patients with a total of 59 affected hips was carried out. In the initial diagnosis the Catterall-, Waldenström- and Herring-stages were assessed. The epiphyseal ratio, the head-neck ratio and the lateral subluxation were measured and compared at the time of diagnosis, fragmentation stage and in a follow-up examination, which was carried out 4, 9 years after diagnosis on the average. The results of the follow-up examination were assessed using the Mose-classification and compared as well. In addition the two classifications were compared as to the necessity of an upgrading. RESULTS: Both classifications yielded similar descriptions of the radiomorphometric course. There was a good correlation between the results of Herring A and Catterall I, Herring B and Catterall II and III and Herring C and Catterall IV. Upgradings were necessary in the Herring- and the Catterall-classification in 21 cases, and 18 cases, respectively. CONCLUSION: The predictive values of both classifications are comparable.

Macrophage reactions in septic arthritis.

With the aid of monoclonal antibodies, macrophages can be split into functionally distinct subpopulations on the basis of their phenotype. Absence of macrophage subtypes has been noted in chronic inflammatory processes, e.g. posttraumatic osteomyelitis, rheumatoid arthritis and sarcoidosis. In the inflammatory focus of acute septic arthritis (n = 13 patients) however, macrophages constitute the majority of immunocompetent cells. The inflammatory macrophage subtype 27E10 was clearly present in increased numbers in 11 of 13 biopsies from the inflammatory foci, showing the effector task of this subtype in synovial resistance. The anti-inflammatory macrophage subset RM3/1 was present in increased numbers in biopsies of infected tissue and the surrounding soft tissue. The occurrence of 25F9-positive macrophages, typical of the late phase of inflammation, varied widely in the biopsies.

Alteration in the pattern of macrophage subtypes in chronic osteomyelitis compared with acute joint infection.

Macrophage subtypes were detected in cryostat sections of biopsies from patients with chronic osteomyelitis, acute joint infections and normal bone marrow, using monoclonal antibodies against different macrophage populations. The resident macrophage subtype 25F9, the gluco-corticoid-inducible macrophage RM 3/1 and the inflammatory type 27E10 were found in abundance in acute infections. They were also present in tissue sections of uninflamed bone marrow. By contrast, in about 50% of the biopsies from patients with chronic osteomyelitis a reduced number of macrophage subtypes, or even the lack of one or more macrophage subpopulations was found. The unusual absence of macrophage phenotypes seems to be restricted to the area of osteomyelitis because in the tissues of inflamed sinuses in these patients, the macrophage subtypes were present. These findings suggest a disturbance at the level of the macrophages which may contribute to the persistence of the inflammatory process in osteomyelitis.

Pattern of macrophage subpopulations in post-traumatic bone infections after combined operative/antibiotic treatment.

Macrophage subpopulations were detected immunohistochemically with the aid of monoclonal antibodies in tissue sections of 15 patients with posttraumatic osteomyelitis at the beginning of therapy and after combined operative/antibiotic treatment. Macrophages represent the majority of the immunocompetent cells in osteomyelitis tissue. Before the start of therapy, the acute inflammatory macrophage subtype 27E10 was absent or rarely found in 8/13 evaluable biopsies from the osteomyelitis focus, and a further decrease in the expression of these macrophage antigens was observed after treatment. The RM3/1-positive macrophage associated with the down-regulation of inflammation was detectable to a low extent in 4/13 evaluable biopsies from the osteomyelitis focus before the start of therapy. After treatment of the infection, an increase in this subtype was found in the cellular inflammatory infiltrates in the tissue samples examined. In 8/15 biopsies a marked expression of the RM3/1 antigen was observed. At the start of treatment, the macrophage 25F9, which dominates in the late phase of inflammation, was missing in 3/13 tissue samples. After combined operative/antibiotic treatment the 25F9-positive macrophage was found in all patients, having increased in 7/14 biopsies studied. These data suggest that treatment of posttraumatic osteomyelitis leads to a local macrophage subtype distribution in the osteomyelitis focus resembling the pattern of a late inflammatory reaction.

Osteocalcin levels in chronic osteomyelitis.

Osteocalcin is a vitamin K-dependent bone protein synthesized by osteoblasts. In generalized bone disorders serum osteocalcin correlates with osteoblast activity. Bone resorption and new bone formation occur in chronic osteomyelitis, dependent on the level of inflammatory activity. In 17 patients with active chronic osteomyelitis undergoing surgery, the serum levels of osteocalcin, alkaline phosphatase and C-reactive protein were measured before and after treatment. The osteocalcin levels were within the normal range preoperatively (10.8 +/- 11.0 micrograms/l), in the early postoperative period, and at discharge. It is therefore not a helpful marker in the clinical management of this condition.

PMN elastase in bone and joint infections.

PMN (polymorphonuclear neutrophil) elastase is a proteolytic enzyme which is a biochemical marker for abnormal granulocyte stimulation. In inflammation and sepsis, excessive neutrophil stimulation results in significant amounts of PMN elastase being released into the plasma which indicates the severity of the disease and its prognosis. In 62 patients with osteomyelitis or suppurative arthritis, PMN elastase had a diagnostic sensitivity of 81%, which is comparable to the nonspecific erythrocyte sedimentation rate. Sensitivity of C-reactive protein (CRP) was 71%, fibrinogen 54% and leucocyte count 26%. PMN elastase was also useful in the follow up of patients with bone and joint infections; in the early post-operative period it became normal more quickly than the other findings unless the patients developed complications. Ten days after operation, PMN elastase was normal in 75% of the patients compared to the CRP which became normal in only 25%. Later both results were similar: on discharge from hospital, PMN elastase was normal in 77% and CRP in 71%.

[Lymphocyte defects in chronic osteomyelitis. A prospective study]. / Lymphozytendefekte bei der chronischen Osteomyelitis. Eine prospektive Studie.

In patients with chronic post-traumatic osteomyelitis, several deficits in immunological response were demonstrated. In a prospective trial of 20 patients with proven osteomyelitis, histological analysis of lymphocyte subsets in peripheral blood and in the infected bone tissue was performed. The effects of chronic osteomyelitis on lymphocyte subsets in the peripheral blood and in inflamed tissue were only slight. The T4/T8 ratio was diminished in only two patients and had no relationship to the clinical course. Interleukin 2 receptor determination was negative in 83% of biopsies of infected tissue. Osteomyelitis may possibly cause a defect in lymphocyte/macrophage cooperation.

[Suppression of macrophage subpopulations in post-traumatic osteomyelitis]. / Verminderung von Makrophagensubpopulationen bei der posttraumatischen Osteomyelitis.

Similar to other chronic inflammatory diseases such as rheumatoid arthritis the distribution of macrophage subtypes seems to be disturbed in post-traumatic osteomyelitis. This atypical distribution is clearly locally restricted in osteomyelitis. 27E10-positive macrophages found only during the acute phase of inflammation were reduced in 39%, the 25F9-positive subtype, predominating in the late stage of inflammation, was missing in 33%. The antiinflammatory macrophage RM3/1 was decreased in 40% of the osteomyelitis biopsies. Local suppression of macrophage subsets has to be discussed as one of the reasons for the persistence of chronic inflammatory processes in osteomyelitis.