A different ontogenesis for chronic lymphocytic leukemia cases carrying stereotyped antigen receptors: molecular and computational evidence.

Chronic lymphocytic leukemia (CLL) is uniquely characterized by the existence of subsets of cases with quasi-identical, 'stereotyped' B-cell receptors (BCRs). Herein we investigate this stereotypy in 2662 patients with CLL, the largest series yet, using purpose-built bioinformatics methods based on sequence pattern discovery. Besides improving the identification of 'stereotyped' cases, we demonstrate that CLL actually consists of two different categories, based on the BCR repertoire, with important biological and ontogenetic differences. The first ( approximately 30% of cases) shows a very restricted repertoire and is characterized by BCR stereotypy (clustered cases), whereas the second includes cases with heterogeneous BCRs (nonclustered cases). Eleven major CLL clusters were identified with antigen-binding sites defined by just a few critically positioned residues, regardless of the actual immunoglobulin (IG) variable gene used. This situation is closely reminiscent of the receptors expressed by cells participating in innate immune responses. On these grounds, we argue that whereas CLL cases with heterogeneous BCRs likely derive from the conventional B-cell pool, cases with stereotyped BCRs could derive from progenitor cells evolutionarily adapted to particular antigenic challenges, perhaps intermediate between a true innate immune system and the conventional adaptive B-cell immune system, functionally similar to what has been suggested previously for mouse B1 cells.

Mason type IV fractures of the elbow: a 14- to 46-year follow-up study.

A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3 degrees (sd 4) and extension by a mean of 9 degrees (sd 4) (p < 0.01). None experienced chronic elbow instability or recurrent dislocation. There were more degenerative changes in the formerly injured elbows, but none had developed a reduction in joint space. We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome.

Displaced fractures of the neck of the radius in adults. An excellent long-term outcome.

We have reviewed 20 women and three men aged 22 to 73 years, who had sustained a Mason type-IIb fracture of the neck of the radius 14 to 25 years earlier. There were 19 patients with displacement of the fractures of 2 mm to 4 mm, of whom 13 had been subjected to early mobilisation and six had been treated in plaster for one to four weeks. Of four patients with displacement of 4 mm to 8 mm, three had undergone excision and one an open reduction of the head of radius. A total of 21 patients had no subjective complaints at follow-up, but two had slight impairment and occasional elbow pain. The mean range of movement and strength of the elbow were not impaired. The elbows had a higher prevalence of degenerative changes than the opposite side, but no greater reduction of joint space. Mason type-IIb fractures have an excellent long-term outcome if operation is undertaken when the displacement of the fracture exceeds 4 mm.

The impact of long-term moderate physical activity on functional performance, bone mineral density and fracture incidence in elderly women.

BACKGROUND: Earlier studies have shown that physical exercise and a higher workload increase muscle strength and improve gait and balance at all ages for both sexes. Published studies have, so far, failed to investigate the functional performance of elderly individuals concerning their long-term physical activity and variables of daily living. OBJECTIVE: To compare elderly women who participate in long-term, moderate exercise programmes with two age-matched groups of women from an urban and a rural community. METHODS: All participants answered a questionnaire about health, social circumstances and fractures. We measured the vibration threshold of the lower extremities, bone mineral density of the distal radius and functional performance such as muscle strength, balance and gait. RESULTS: The elderly, active groups performed significantly better in all functional tests and had sustained fewer fractures than the urban control group. When the comparison was made with the rural control group the differences were less obvious. The active group rated their health as better than both the control groups. CONCLUSION: Elderly women, who continue with moderate exercise programmes over many years, sustain fewer fractures and have better muscle strength, balance, gait and health ratings than women in general. Whether this is the result of the exercise or inherited characters, remains to be proved.

Bone loss following tibial osteotomy: a model for evaluating post-traumatic osteopenia.

The reduced bone mineral density (BMD) found in patients with fractures may, in part, follow rather than precede the fracture. We studied the magnitude and reversibility of bone loss in the 15 months following osteotomy in 21 men and 5 women with localized medial arthritis of the knee. BMD (mean +/- SD), measured using dual-energy X-ray absorptiometry, decreased by a maximum of 35 +/- 21% in the mid-diaphysis of the affected tibia at 9 months after surgery (p < 0.001). At 15 months, reversal of bone loss in non-fractured bones was incomplete; the remaining deficit was 20 +/- 27% relative to baseline (p < 0.001). Maximum bone loss occurred at 9 months at the total body (5 +/- 2%), spine (15 +/- 17%) and at Ward's triangle of the proximal femur of the unoperated limb (10 +/- 17%) (all p < 0.01). In summary, post-traumatic bone loss is region-specific with incomplete reversibility, at least after about 15 months. Deficits in BMD in cross-sectional studies of patients with fractures, held to be responsible for the bone fragility, may, in part, follow rather than precede the fracture.

Pin-tract complications in external fixation of fractures of the distal radius.

We analyzed retrospectively the rate and outcome of pin-tract complications in 314 unstable fractures of the distal radius, treated with the Hoffmann small-frame external fixator. The overall rate of complications was 27%. The commonest complication (21%) was pin-tract infection, which was treated with oral antibiotics. There were no cases of osteitis. Complications led to premature removal of the fixator in 17 of the cases. Women over the age of 75 years had a significantly higher rate of pin loosening (17%), but not a higher rate of premature removal of the fixator due to complications. 4% of the cases had a pin-site fracture, all women. The rate of pin-tract complications was high, but severe complications were rare, even in old women.

Closed treatment of Jones fracture. Good results in 40 cases after 11-26 years.

40 patients with transversal or short oblique fractures of the proximal shaft of the fifth metatarsal bone (Jones fracture) were treated with full weight bearing with or without elastic bandage in 39 cases and plaster cast immobilization in one. 24 cases were acute traumatic fractures, 14 stress fractures and 2 refractures. After 17 (11-26) years, 33 of the fractures had healed primarily, evidence of refracture or delayed union was found in 7 and there were no non-unions. All but one of the patients were free of symptoms.

Jones fracture. Surgical versus nonsurgical treatment.

Sixty-three patients with 66 transverse and short oblique fractures of the proximal shaft of the fifth metatarsal bone (Jones fracture) were evaluated an average of five years (range, one to ten years) after the injury. There were 27 acute fractures and 39 chronic, or stress, fractures. The primary treatment was surgical for one third of the injuries and nonsurgical for the others. Surgical treatment consisted of the insertion of medullary screws. Nonsurgical treatment consisted of the application of either a plaster cast or an elastic bandage. Almost one fourth of the fractures treated nonsurgically later had to be treated surgically because of delayed unions or refractures. Late surgery was required in 12% of acute fractures and in 50% of chronic fractures with sclerosis narrowing the medullary canal. Irrespective of the primary treatment, all the patients had full function at the time of the follow-up evaluation, and no nonunions were diagnosed.

Osteochondritis dissecans of the elbow. A long-term follow-up study.

Thirty-one patients with osteochondritis dissecans of the capitellum humeri were followed for an average of 23 years. There were symptoms in about half of the elbows at the follow-up examination. Impaired motion and pain on effort were the most common complaints. Roentgenographic signs of degenerative joint disease were present in more than half of the elbows and correlated with a reduced range of motion. The diameter of the radial head increased in comparison with the contralateral elbow in two thirds of the patients.

Effects of physical activity on bone mineral content and muscle strength in women: a cross-sectional study.

Physical exercise is known to increase bone mass in men, whereas the effect is less predictable in women. In this cross-sectional report, effects of physical activity on women aged 38-64 years are studied. Bone mass and muscle strength were compared between 30 regularly exercising women jogging only once a week for at least three years and an equal number of controls matched for age. BMC of the distal third of the radius was significantly higher in the active women. The active women over age 50 also had higher trabecular bone mass in the distal end of the radius. Quadriceps strength and balance were also found to be better in the activity group. Active women had a different lifestyle than the non-active women, with less consumption of alcohol, oestrogens, and tobacco. This report supports the hypothesis that regular moderate physical activity might reduce bone loss in women.

Avulsion of the cervical spinal ring apophyses: acute and chronic appearance.

Avulsion of the superior or inferior ring apophyses of the cervical spine was found in 12 of 1922 patients aged 10-20 years. Clinical and radiological follow-up of 9 of these patients was undertaken 3-25 years after trauma. Avulsion of the superior apophysis occurs after flexion, while extension trauma causes avulsion of the inferior ring apophysis. The follow-up appearance is characteristic in both instances. In superior ring apophysis avulsion, there is a bow shape of the superior aspect of the involved vertebral body. In inferior avulsion, the avulsed apophysis fuses with the vertebral body and forms an "osteophyte", whose shape and size depend on the degree of displacement.

Dislocations of the elbow and intraarticular fractures.

Of 23 patients with an elbow dislocation associated with at least one displaced fracture of the radial head, 19 patients had the radial head extirpated two days range, 0-16 days) after injury. In four elbows, redislocation occurred. All four redislocations were associated with a displaced fracture of the coronoid process. A follow-up examination was performed in 19 patients between three and 34 years after the injury. Severe osteoarthritis with reduced joint space developed in 12 elbows. Reduced range of motion was the most common complaint, and reduced extension was the most common finding. To lower the risk and prevent severe instability, the radial head should be preserved if possible. If the radial head must be resected, suturing of torn ligaments and muscles at the epicondyles is essential.

Ligamentous injuries in dislocations of the elbow joint.

The opinions concerning presence of instability and ligamentous injuries following dislocation of the elbow differ. Thirty-one patients with an elbow dislocation without concomitant fracture were examined under anesthesia for stability at an average time of two days after the injury. All elbows were unstable to valgus stress in the extended position compared with the healthy side. Eight elbows were unstable to varus stress. Nine elbows were easily redislocated in semiflexed position under anesthesia. Surgical exposure and ligament suture were performed medially in all cases and laterally in 18 cases. All the ligaments were completely ruptured or avulsed in the epicondyle attachment. In most cases the ligamentous ruptures were combined with rupture or avulsion of the muscular origins at the epicondyles. The degree of muscular damage was correlated with the tendency to redislocate under anesthesia.

Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study.

Thirty consecutive patients who had dislocation of the elbow without concomitant fracture and who were sixteen years old or more were examined under general anesthesia for stability of the joint at an average of four days after the injury. All of the elbows showed medial and sixteen showed both medial and lateral instability. The patients were then randomly assigned to undergo either non-surgical or surgical treatment of the ligamentous injuries. All of the surgically treated elbows showed complete rupture or avulsion of both the medial and lateral collateral ligaments, and in about half of these patients the muscle origins were found to be torn from the humeral epicondyles. At follow-up, both groups showed generally good results; the differences were not statistically significant. There was no evidence that the results of surgical repair of the ligaments were any better than those of non-surgical treatment.

Surgical versus nonsurgical treatment of ligamentous injuries following dislocations of the elbow joint.

Sixty-two patients older than 16 years of age at the time of injury were reexamined an average of five years (range, 1 to 12 years) after a dislocation of the elbow without concomitant fracture. Thirty-four were treated nonsurgically with closed reduction and immobilization in a plaster cast. Twenty-eight were treated surgically with primary ligament repair followed by immobilization in plaster. Ligament repair was performed medially in all cases and laterally in 17, on the average two days after injury. At follow-up examination, the most common complaint in both groups was limited range of motion, decreased extension being the most common. In no respect were the surgically treated elbows better than those treated nonsurgically. No evidence was found to recommend primary surgical treatment of ligament injuries associated with dislocation of the elbow.

Incidence of elbow dislocation.

Totally, 178 elbow dislocations--with and without concomitant fracture--that had occurred in the city of Malmö in the course of 12 years were studied. There was some preponderance of left-sided injury, but no significant sex difference. The dislocations were most frequent in the very young and occurred most often in conjunction with sports activities.

Epicondylar elbow fracture in children. 35-year follow-up of 56 unreduced cases.

Fifty-six conservatively treated children (7-17 years) with a displaced (1-15 mm) fracture of the medial humeral epicondyle were examined 35 (21-48) years after the injury. In 31 cases a pseudarthrosis had developed of which 3 had mild ulnar nerve symptoms. The function and range of motion of the elbow was good in all cases.

Long-term sequelae of simple dislocation of the elbow.

Fifty-two patients with a radiographically verified dislocation of the elbow were re-examined at an average of twenty-four years after injury. Half of the patients had no residual symptoms or signs whatsoever and more than one-third had a slight or moderate decrease in the range of extension, which was associated with slight degenerative change in the joint or with periarticular calcification. No reduction in joint space was evident. Even when the examination revealed some instability in a few patients they did not register complaints. Among the patients who had sustained the injury when they were less than sixteen years old, there were few with residual symptoms, signs, or radiographic changes.

Arthrography of the dislocated elbow joint.

Arthrography has been suggested as a useful tool for diagnosing ligament ruptures. In 14 consecutive patients with non-fractured elbow dislocations arthrography was performed after reduction of the dislocation. One or two days following arthrography all elbows were examined under general anesthesia with regard to stability and half of them were randomized for surgery with exploration and suture of both the ulnar and the radial collateral ligaments. Arthrography, even if performed within 24 hours after the injury, was found to be unreliable in diagnosing ligament injuries after elbow dislocation. Leakage of the contrast medium was more or less limited to the site of the major injury, which in the dorsal and dorso-radial dislocation was a rupture of the volar aspect of the capsule and the ulnar side of the joint in the radial dislocation.