A practical method to achieve prostate gland immobilization and target verification for daily treatment.

PURPOSE: A practical method to achieve prostate immobilization and daily target localization for external beam radiation treatment is described. METHODS AND MATERIALS: Ten patients who underwent prostate brachytherapy using permanent radioactive source placement were selected for study. To quantify prostate motion both with and without the presence of a specially designed inflatable intrarectal balloon, the computerized tomography-based coordinates of all intraprostatic radioactive sources were compared over 3 consecutive measurements at 1-min intervals. RESULTS: The placement and inflation of the intrarectal balloon were well tolerated by all patients. The mean (range) displacement of the prostate gland when the intrarectal balloon was present vs. absent was 1.3 (0-2.2) mm vs. 1.8 (0-9.1) mm (p = 0.03) at 2 min respectively. The maximum displacement in any direction (anterior-posterior, superior-inferior, or right-left) when the intrarectal balloon was inflated vs. absent was reduced to < or =1 mm from 4 mm. CONCLUSIONS: Both prostate gland immobilization and target verification are possible using a specially designed inflatable intrarectal balloon. Using this device, the posterior margin necessary on the lateral fields to ensure dosimetric coverage of the entire prostate gland could be safely reduced to 5 mm and treatment could be set up and verified using a lateral portal image.

Recombinant human manganese superoxide dismutase attenuates early but not delayed skeletal muscle dysfunction following reperfusion injury.

OBJECTIVES: to assess the efficacy of recombinant human manganese superoxide dismutase (rhMnSOD) in prevention of early and late skeletal muscle ischaemia-reperfusion injury mediated by superoxide (O2-). Design : randomised controlled trial. MATERIALS: seventy-two Sprague-Dawley rats (250-350 g) randomised to receive either 7.5 mg/kg of rhMnSOD or saline. Four hours of ischaemia was induced in the cremaster muscle by dissecting free and clamping its vascular supply. Cremaster muscle contractile function was assessed following 90 minutes, 24, 48 hours and one week of reperfusion. Electrophysiological muscle function was assessed using electrical field stimulation in an organ bath system. RESULTS: muscle function in the untreated groups following ischaemia reperfusion was significantly reduced at 90 minutes, 24, 48 hours and one week of reperfusion (p <0.05). rhMnSOD significantly protected and maintained normal muscle function at 24 and 48 hours (p <0.001). However at one week of reperfusion there was a reduction in function of the treated muscle, such that there was no significant difference between treated and untreated muscle at this point in time. CONCLUSIONS: these data demonstrate that skeletal muscle dysfunction after ischaemia reperfusion injury is attenuated at 24 and 48 hrs of reperfusion by the superoxide scavenger rhMnSOD. This protective effect is not maintained after seven days of reperfusion.

Chymopapain chemonucleolysis: a review of 105 cases.

A review of 105 consecutive cases of chymopapain chemonucleolysis for single level lumbar disc herniation was undertaken. Mean follow-up was 12.2 years (range 10-15.3). Patients were assessed using the Oswestry Disability Questionnaire. Eighty-seven patients were available for follow-up. An excellent or good response occurred in 58 patients (67%); four patients (4.5%) had a moderate response but were only minimally disabled. The treatment failed in 25 patients (28.5%) and 21 of these went on to surgery within a mean of 5.2 months (range 3 weeks-12 months). In 15 patients (71%) disc sequestration or lateral recess stenosis was found. Five of the remaining six cases had a large disc herniation at surgery. Surgery resulted in a significant improvement in nine cases. Discitis following chemonucleolysis occurred in six patients (5.7%). Chymopapain chemonucleolysis has a useful role in the management of lumbar intervertebral disc prolapse. However, its efficacy is dependent on careful clinical and radiological patient selection.

Sparing of sensation to pin prick predicts recovery of a motor segment after injury to the spinal cord.

We have reviewed 59 patients with injury to the spinal cord to assess the predictive value of the sparing of sensation to pin prick in determining motor recovery in segments which initially had MRC grade-0 power. There were 35 tetraplegics (18 complete, 17 incomplete) and 24 paraplegics (19 complete, 5 incomplete), and the mean follow-up was 29.6 months. A total of 114 motor segments initially had grade-0 power but sparing of sensation to pin prick in the corresponding dermatome. Of these, 97 (85%) had return of functional power (> or = grade 3) at follow-up. There were 479 motor segments with grade-0 power but no sparing of sensation to pin prick and of these only six (1.3%) had return of functional power. Both of the above associations were statistically significant (chi-squared test, p < 0.0001). After injury to the spinal cord, the preservation of sensation to pin prick in a motor segment with grade-0 power indicated an 85% chance of motor recovery to at least grade 3.

Major pelvic injuries in equestrian sports.

A series of pelvic and acetabular injuries caused by horse riding accidents is reported. The importance of wearing appropriate protective clothing when riding is emphasised.

An epidemic of roller-blade injuries in children.

Roller blading is a new and increasingly popular leisure activity in many countries. We reviewed 110 consecutive patients with roller-blade injuries between 1 January and 30 June 1996. The patients ranged from 4 to 14 years in age (mean 6.5 years). Eighty-three (75.4%) sustained injuries to the upper limb and 27 (24.5%) injured the lower limb. Fifty-six patients, were girls and 54 were boys. Of the 110 patients, 79 (72.7%) sustained fractures, 28 (25.4%) soft tissue injuries and 3 (2.7%) dislocations. Eighty-three (75.4%) of the patients wore no protective equipment on the limbs. Four months following injury 103 (93.6%) patients were fully recovered. The mean duration of school absence was 3 days. Subsequently 101 children returned to using roller-blades following injury. Seventy-three (66.3%) of these now use protective equipment. We found that injuries were unrelated to age or duration of roller-blading experience or to the brand-name of roller blades used, and that most of our patients wore no protective equipment at the time of injury.

An evaluation of the factors affecting neurological recovery following spinal cord injury.

We reviewed 71 consecutive spinal cord injuries to determine the factors influencing neurological recovery. Sixty-three (35 tetraplegics and 28 paraplegics) were available for follow-up at a mean of 29.6 months. The American Spinal Injury Association (ASIA) scoring system was used on admission and at follow-up to determine change in neurological status. Treatment with corticosteroids or surgical intervention had no significant effect on outcome. Tetraplegics, both complete and incomplete, had a significantly better outcome than paraplegics (p < 0.02). Incomplete cord injury carried a better prognosis of motor recovery (p < 0.0001). Pattern of injury was an important determinant of recovery in the complete tetraplegia group. We conclude that many factors influence recovery following spinal cord injury and the effect of treatment may be difficult to demonstrate.

Long-term follow-up of 50 Duke silicone prosthetic fingers.

Thirty-three patients with single and multiple digital amputations were fitted with a total of 50 prosthetic silicone fingers over a mean period of 4 years. The prosthetic fingers were custom made using a special method which has been modified at our institution. This study provides a detailed analysis of patients' occupational and cosmetic usage of and satisfaction with their prostheses, as well as describing the fabrication technique.

Fibular osteochondroma presenting as chronic ankle sprain.

A 19-year-old baseball player was referred for assessment of recurrent sprains of the right ankle. This was found to be secondary to a palsy of the common peroneal nerve that was compressed by an osteochondroma of the fibular neck. The lesion was resected from the fibula and the patient made a complete recovery. We present this case as an example of a rare underlying problem in a patient who was initially diagnosed as having a sports-related ankle injury.

Evaluation of the optimal hand-scrub duration prior to total hip arthroplasty.

Orthopaedic surgeons in many major arthroplasty centres advocate the use of a prolonged surgical hand-scrub prior to total joint replacement. In this study we evaluated the antimicrobial efficacy of a 5 compared with a 10 min scrub before both long (> 90 min) and short (< 90 min) operations for total hip arthroplasty. Surgical hand disinfection was performed on one occasion for 5 min and on a second for 10 min by 41 surgeons and theatre nurses using 4% chlorhexidine gluconate as a detergent formulation ('Hibiscrub', ICI Pharmaceuticals). None of the subjects had previously scrubbed on the day of each test. Bacterial colony counts on the fingers were measured using the method described by Rotter (vide infra) before scrubbing, immediately after scrubbing, and at the end of each operation. Our results showed that for arthroplasty procedures lasting less than 90 min (35 operations) a 5 min hand-scrub was equally as effective as one of 10 min. However, following longer procedures (36 operations) colony counts were significantly higher on subjects who had scrubbed for 10 min than on those who only scrubbed for 5 (P < 0.05, Mann-Whitney U-Test). This study suggests that the practice of a prolonged scrub before total joint replacement does not have a scientific basis and that such a policy should be discontinued where it is still practised.

Fractures of the os calcis: improved results with internal fixation.

A prospective study of 24 patients with displaced intra-articular fractures of the os calcis was performed to compare operative with non-operative treatment. Twelve patients were treated by internal fixation followed by early mobilization, and 12 were managed non-operatively. The patients were assessed 15 months later using eight parameters. Of the 12 patients who were treated by internal fixation, eight had returned to work. Walking distance was significantly longer (4 km) in this group and only one patient needed a change in shoe size. Of the 12 patients who were managed non-operatively, only three had returned to work and eight had a change in shoe size, while the average walking distance without pain was only 1 km. The mean range of subtalar movement was 24 degrees in the operated group but only 12 degrees in the other group (P < 0.05). Radiological follow-up demonstrated partial or full restoration of Böhler's angle in the patients who underwent internal fixation. We recommend plating of displaced intraarticular os calcis fractures through a lateral approach in patients under 40 years of age.