Mesenchymal stromal cell injection promotes vocal fold scar repair without long-term engraftment.

BACKGROUND: Regenerative medicine holds promise for restoring voice in patients with vocal fold scarring. As experimental treatments approach clinical translation, several considerations remain. Our objective was to evaluate efficacy and biocompatibility of four bone marrow mesenchymal stromal cell (BM-MSC) and tunable hyaluronic acid based hydrogel (HyStem-VF) treatments for vocal fold scar using clinically acceptable materials, a preclinical sample size and a dosing comparison. METHODS: Vocal folds of 84 rabbits were injured and injected with four treatment variations (BM-MSC, HyStem-VF, and BM-MSC in HyStem-VF at two concentrations) 6 weeks later. Efficacy was assessed with rheometry, real-time polymerase chain reaction (RT-PCR) and histology at 2, 4 and 10 weeks following treatment. Lung, liver, kidney, spleen and vocal folds were screened for biocompatibility by a pathologist. RESULTS AND DISCUSSION: Persistent inflammation was identified in all hydrogel-injected groups. The BM-MSC alone treatment appeared to be the most efficacious and safe, providing an early resolution of viscoelasticity, gene expression consistent with desirable extracellular matrix remodeling (less fibronectin, collagen 1α2, collagen 3, procollagen, transforming growth factor [TGF]ß1, alpha smooth muscle actin, interleukin-1ß, interleukin-17ß and tumor necrosis factor [TNF] than injured controls) and minimal inflammation. Human beta actin expression in BM-MSC-treated vocal folds was minimal after 2 weeks, suggesting that paracrine signaling from the BM-MSCs may have facilitated tissue repair.

[Chondrocalcinosis of the temporomandibular joint revealed by a hearing loss: a case report]. / Une chondrocalcinose de l'articulation temporo-mandibulaire révélée par une hypoacousie: à propos d'un cas.

INTRODUCTION: Chondrocalcinosis is a microcrystalline arthropathy that principally affects the knee. It is a rare disorder, usually asymptomatic, that occurs mainly in the elderly people. PURPOSE: To report a case of a temporomandibular joint chondrocalcinosis with ossicular contact revealed by a conductive hearing loss. CASE REPORT: We describe the case of a 57-year-old man with a right conductive sudden hearing loss of 15 dB. The CT scan revealed a lytic lesion in the right attic extended to the middle cerebral fossa in contact with the ossicles with a suspicion of lysis of the head of the malleus. MRI showed a lesion enhancing after gadolinium injection on T1 weighted images. A biopsy revealed a chondrocalcinosis of the temporomandibular joint. Due to the complexity of surgical excision and the benin character of the lesion, a medical treatment and a radiologic follow-up every six months were proposed. CONCLUSION: Chondrocalcinosis of the temporo-mandibular joint is rare especially when it is revealed by a hearing loss. We present here a review of the literature.

Evaluation and treatment of dural tears in lumbar spine surgery: a review.

Incidental durotomy is a frequent complication of lumbar spinal surgery. The number and complexity of spinal procedures is increasing, leading to a greater prevalence of dural tears; therefore, it is imperative that spine surgeons be familiar with safe and effective closure techniques. Occasionally, a tear may not be recognized during the procedure, so that one must recognize the signs and symptoms of a cerebrospinal fluid leak postoperatively. Several newer treatment concepts show promise. The current study represents an extensive review of the recent literature on the prevalence, mechanism, diagnosis, treatment, and outcomes of dural tears. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author's technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid.

The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx.

Stubbing injuries to the great toe can be a cause of occult open fractures and osteomyelitis. Five such patients were identified after conducting a retrospective review of injuries to the hallux between January 1998 and December 1998. The study was conducted to draw attention to the association between this trivial trauma and its possible complications. All five children had open fractures of the distal phalanx of the great toe. Osteomyelitis did not develop in the children whose injuries were recognized early and who were treated with antibiotics. However, three children with delayed diagnoses and treatment developed osteomyelitis. At a mean follow-up of 10 months (range, 9-11) after injury, all five fractures had healed with no active signs of infection. Two of these children experienced a partial growth arrest and two experienced a full growth arrest of the distal phalanx of the great toe, the significance of which is yet unknown. Clinical signs such as bleeding from the eponychium and a laceration proximal to the nail bed should alert physicians to the presence of a possible open fracture. Early detection and treatment of these injuries may reduce or eliminate hospital stays and prolonged intravenous antibiotic treatment for osteomyelitis.

Development dysplasia of the hip from birth to six months.

The term "developmental dysplasia or dislocation of the hip" (DDH) refers to the complete spectrum of abnormalities involving the growing hip, with varied expression from dysplasia to subluxation to dislocation of the hip joint. Unlike the term "congenital dysplasia or dislocation of the hip," DDH is not restricted to congenital problems but also includes developmental problems of the hip. It is important to diagnose these conditions early to improve the results of treat- ment, decrease the risk of complications, and favorably alter the natural history. Careful history taking and physical examination in conjunction with advances in imaging techniques, such as ultrasonography, have increased the ability to diagnose and manage DDH. Use of the Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If stable reduction cannot be obtained after 2 weeks of treatment with the Pavlik harness, alternative treatment, such as examination of the hip under general anesthesia with possible closed reduction, is indicated. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step. Toward the end of the first year of life, the toddlerTs ability to stand and bear weight on the lower extremities, as well as the progressive adaptations and soft- tissue contractures associated with the dislocated hip, preclude use of the Pavlik harness.

Legg-Calvé-Perthes disease in girls. A comparison of the results with those seen in boys.

We reviewed the records and roentgenograms of all patients with Legg-Calvé-Perthes disease who had been seen at our institution between 1940 and 1996. One hundred and five girls (122 hips) and 470 boys (531 hips) were identified. Thus, 18 per cent of the 575 patients in the present series were girls. Seventeen (16 per cent) of the girls and sixty-one (13 per cent) of the boys had bilateral involvement. Although more girls than boys had severe involvement of the femoral head and the lateral pillar, we could not detect a significant difference between the two groups with respect to the distribution of the involvement of the hips according to the system of Catterall or the lateral pillar classification (p > 0.05, beta = 0.99). Serial roentgenograms that showed all four stages of the disease according to the system of Waldenström were available for fifty-two hips in girls and 184 hips in boys. A review of these roentgenograms revealed that the average ages of the girls at the stages of necrosis, fragmentation, reossification, and remodeling were 6.8, 7.3, 7.9, and 9.5 years, respectively, whereas the average ages of the boys were 6.8, 7.3, 7.9, and 9.9 years, respectively. Girls, however, had closure of the affected proximal femoral physis at an average age of 12.9 years, whereas boys had closure at an average age of 15.8 years. Therefore, girls had a shorter potential period for remodeling of the femoral head (average, 3.4 years) compared with boys (average, 5.9 years). Sixty-four girls (seventy-eight hips) and 363 boys (416 hips) had reached skeletal maturity by the time of the latest follow-up and were evaluated according to the system of Stulberg et al.; we could not detect a significant difference between boys and girls with respect to the distribution of the hips according to this system (p > 0.05, beta = 0.99). Although the numbers were too small for statistical analysis, our findings suggest that boys and girls who have the same Catterall or lateral pillar classification at the time of the initial evaluation can be expected to have similar outcomes according to the classification system of Stulberg et al.

Computed tomography for femoral and tibial torsion in children with clubfoot.

Forty-seven children with 70 clubfeet had computed tomography studies performed to determine the degree of femoral, tibial, and total limb torsion in both lower limbs. The total limb torsion angle (angle between the axis of the femoral neck and the axis of the ankle), which describes the relationship between femoral and tibial torsion, was used to evaluate the whole rotational deformity of the lower limb. The children were between the ages of 2 and 10 years (mean, 5 years) at the time of the computed tomography study. The mean femoral torsion was 25 degrees in the limbs with a clubfoot and 23 degrees in the contralateral limbs of patients with a unilateral clubfoot. The mean tibial torsion was 25 degrees in the limbs with a clubfoot and 24 degrees in the contralateral limb of patients with a unilateral clubfoot. The authors observed decreases of anterior femoral torsion corresponding to increases in age, consistent with the observations made by other authors of studies of children without clubfoot. External tibial torsion increased with age, with similar values in limbs with and without clubfoot. Ten limbs (nine with clubfoot, one without clubfoot) had femoral torsion greater than the means plus one standard deviation and 12 limbs (eight with clubfoot, four without clubfoot) had tibial torsion less than the means minus one standard deviation. The authors found four limbs (all with clubfoot) in three patients with lower than the mean minus one standard deviation of the total limb torsion angle (intoeing). Overall, there was no appreciable difference in the amount of femoral or tibial torsion in limbs with and without a clubfoot.

Spontaneous union of a congenital pseudarthrosis of the tibia after Syme amputation.

A 4-year-old boy with congenital pseudarthrosis of the tibia had two unsuccessful operative attempts for union. After these procedures the patient had a 6-cm leg length discrepancy and an equinovalgus foot deformity. Because of these deformities he underwent Syme amputation at the ankle and was fitted with a total contact prosthesis. Eight months after the amputation, a solid union was seen across the pseudarthrosis site, although no attempt was made to achieve union with internal fixation or bone grafting. The authors think that vertical alignment of the limb in a total contact prosthesis, along with the compressive forces of weightbearing, allowed the pseudarthrosis site to heal in the patient.

Fibrous dysplasia of the proximal part of the femur. Long-term results of curettage and bone-grafting and mechanical realignment.

We reviewed the long-term outcomes of treatment of fibrous dysplasia of the proximal part of the femur in twenty-two patients (twenty-seven femora). There were fifteen male patients and seven female patients. Patients who had monostotic disease had no involvement of the calcar femorale, fewer microfractures, less deformity, and stronger bone that could support internal fixation. Patients who had polyostotic disease had frequent involvement of the calcar femorale; more microfractures; severe deformity, including shepherd's crook deformity; and, in many instances, bone that could not support internal fixation. Twenty-two of the twenty-seven femora had a microfracture at the time of the initial presentation. At least one osteotomy was performed in four femora that had monostotic disease and in nine femora that had polyostotic disease. Curettage and cancellous or cortical bone-grafting did not appear to have any advantage compared with osteotomy alone in the treatment of symptomatic lesions, as all grafts resorbed with persistence of the lesion. At the time of the latest follow-up evaluation, no lesion had been eradicated or had decreased in size. A satisfactory clinical result was achieved in twenty patients (twenty-four femora): nine who had monostotic disease and eleven who had polyostotic disease. Two patients who had polyostotic disease and an endocrinopathy (one of whom had bilateral involvement) had an unsatisfactory result. All three femora in these two patients had a neck-shaft angle of less than 90 degrees at the time of the most recent follow-up evaluation. Varus deformity of the proximal part of the femur is best treated with valgus osteotomy and internal fixation early in the course of the disease. If the calcar of the femoral neck is involved or if the quality of the bone is such that internal fixation is not possible, a medial displacement valgus osteotomy can provide a more mechanically favorable position for healing of the microfracture.

Delayed union following stress fracture of the distal fibula secondary to rotational malunion of lateral malleolar fracture.

We present a case of delayed union following stress fracture of the distal fibula secondary to rotational malunion of a lateral malleolar fracture. The patient underwent operative excision of the nonunion, plating with autogenous iliac bone grafting, and correction of the malrotation of the distal fibular fragment. The fracture healed, and the patient was asymptomatic with full range of motion at follow-up. This report documents an unusual etiology, "external malrotation," for delayed union of a fibular stress fracture.

Physeal surgery: indications and operative treatment.

The evaluation and treatment of problems that can be corrected by surgery on the growth plate have changed somewhat in recent years; therefore, it is the purpose of this article to update the reader on these advances, as well as review the basic concepts. We review the radiographic evaluation of problems in the extremities and detail key points of physeal operative techniques for correcting problems occurring with growth.

Management of dislocated hips with Pavlik harness treatment and ultrasound monitoring.

We studied the outcome of ultrasound-monitored Pavlik harness treatment of 47 infants (nine boys and 38 girls) with 55 frankly dislocated hips documented by dynamic ultrasonography. The success and failure groups were of similar ultrasound status (hip-status score) at the time of initial examination, but a significant difference emerged at the 7- and 14-day examinations. Detection of frank dislocation and institution of treatment with the Pavlik harness within 3 weeks of birth increased the probability of a successful result. Of 33 infants (27 girls and six boys) with 41 dislocated hips who were seen before the age of 21 days, 26 (63%) hips were reducible in the Pavlik harness alone, and 15 (37%) hips were irreducible and required a subsequent procedure to achieve reduction. Fourteen infants (three boys and 11 girls) with 14 dislocated hips were first seen after the age of 21 days. Three (20%) were successfully treated in the Pavlik harness alone, and 11 (80%) required further treatment. In our opinion, persistent dislocation without improvement after 3 weeks of treatment in the Pavlik harness mandates discontinuation of use of this device. No anatomic factors were seen at the time of the initial ultrasound examination that permitted prediction of those hips likely to succeed or fail treatment with the Pavlik harness.

Distal tibiofibular diastasis secondary to osteochondroma in a child.

An 18-month-old girl with a distal tibiofibular diastasis secondary to an osteochondroma was seen with a valgus deformity of the ankle. The patient underwent operative excision of the osteochondroma at the age of 2 years. At 13-year followup there was resolution of the diastasis, and the patient was free of symptoms. Early excision obviates the need for complex reconstructive surgery to correct ankle deformity later.

Charcot-Marie-Tooth disease associated with hip dysplasia: a case report.

A 31-year-old woman with a known history of hip dysplasia was found to have Charcot-Marie-Tooth disease following abnormal conduction studies done at the time of surgery. Physical examination in this patient was otherwise normal, and the diagnosis of Charcot-Marie-Tooth disease had not been previously considered. This report demonstrates the importance of keeping in mind the association between hip dysplasia and Charcot-Marie-Tooth disease.

Köhler's bone disease of the tarsal navicular.

Fourteen patients with Köhler's bone disease of the tarsal navicular in 16 feet were reviewed at an average follow-up of 31 years 6 months after diagnosis. The type and length of treatment did not affect the final outcome; however, short-leg cast immobilization did decrease the duration of symptoms. Two feet were symptomatic at the time of follow-up: one foot had a talocalcaneal coalition with degenerative changes, and the other foot had a large accessory navicular. Both of these feet were rated as having a fair result. The remaining 12 feet were classified as having a good result. Patients with Köhler's bone disease can be expected to have a normal foot at adulthood. Should the patient become symptomatic, other causes of foot pain should be investigated.

Clubfeet associated with congenital constriction bands of the ipsilateral lower extremity.

The purpose of this study was to examine the outcome of treatment of clubfeet distal to a lower extremity constriction band. Eighteen patients with 21 clubfeet distal to a lower extremity constriction band were treated during the years 1946 to 1992. Three types of bands (I to III) were defined. Three grades of feet (A to C), based on the severity of the deformity, were recognized. After treatment, the feet were classified as good, fair, or poor. At follow-up, six of 18 feet were classified as good, six as fair, and nine as poor. These results were correlated with the type of band and the grade of the foot. A grade A foot associated with type III band had the best result.

The natural history of Klippel-Feil syndrome: clinical, roentgenographic, and magnetic resonance imaging findings at adulthood.

Twenty-two patients (15 women and seven men) with Klippel-Feil syndrome were reviewed at an average age of 35 years (range, 26-57 years). The average age at diagnosis was 9 years (range, birth-32 years). All patients had a clinical neurologic and orthopaedic examination. Ten patients (45%) had abnormal findings on clinical examination, and 15 patients (68%) had at least one complaint that could be related to the syndrome. The roentgenograms were unremarkable in all patients, except for the typical findings of congenital fusion; no vertebral subluxation or stenosis was noted in any patient. The magnetic resonance images revealed degenerative changes in the disks of 100% of the patients, evidenced by a low-intensity signal on the T2-weighted images. Nineteen patients (86%) had abnormal findings on the magnetic resonance imaging scans, including disk protrusion (16 patients), osteophytes (four patients), syringomyelia (four patients), and narrowing at the level of the craniovertebral junction (six patients). Our results confirm the well-held belief that the Klippel-Feil syndrome can cause problems in adult life.

Congenital dislocation of the hip in boys.

Fifty-five boys with seventy-eight congenitally dislocated hips were treated between 1965 and 1990. The patients were divided into three groups according to the initial treatment. Group I included thirty hips (twenty-two boys) that had been treated initially with a Pavlik harness. Two hips (7 per cent) had a successful outcome, and twenty-eight (93 per cent) needed additional methods of treatment. Group II included forty-two hips (twenty-nine boys) that had been treated initially with closed reduction and immobilization in a hip-spica cast. After the closed reduction, twenty-nine hips (69 per cent) were considered stable, although fifteen (52 per cent) of them needed a secondary procedure because of residual subluxation or persistent acetabular dysplasia. Thirteen hips (31 per cent) were considered unstable after the closed reduction and subsequently had an open reduction. Group III included six hips (four boys) that had been treated initially with open reduction. Two of these hips redislocated after the open reduction, and they were reduced with an additional open reduction. A pelvic osteotomy was later performed to treat persistent acetabular dysplasia in these two hips. Two hips that had been treated with an open reduction and concomitant pelvic and femoral procedures did not need additional treatment. This study demonstrates that boys who have congenital dislocation of the hip do not always respond well to treatment and constitute a high-risk group.

Rotation of the spine in congenital scoliosis.

We reviewed the progression of spinal rotation in 100 consecutive patients with 119 curves. Eighty-four patients had a single curve and composed this study. Thirty-nine cases were due to failure of segmentation, 38 cases were due to failure of formation, and seven cases were unclassifiable. Sixty-five of the patients eventually underwent spinal arthrodesis, and 19 of the patients were treated with nonoperative means, such as bracing or observation. Cases of unilateral bar, hemivertebra, and wedge vertebra showed progressive rotation, regardless of the type of treatment; however, progression of curve magnitude was limited by spinal arthrodesis. Rotation of the spine was not seen in patients with block vertebrae. Rotation of the spine and progression of curve magnitude varied in cases of complex vertebral deformities. Because of the uncertainty of remaining growth potential in congenitally dysplastic vertebrae, future growth in the spine should be considered before the undertaking of operative procedures.