Metallo-protease Peptidase M84 from Bacillusaltitudinis induces ROS-dependent apoptosis in ovarian cancer cells by targeting PAR-1.

We have purified Peptidase M84 from Bacillus altitudinis in an effort to isolate anticancer proteases from environmental microbial isolates. This metallo-protease had no discernible impact on normal cell survival, but it specifically induced apoptosis in ovarian cancer cells. PAR-1, a GPCR which is reported to be overexpressed in ovarian cancer cells, was identified as a target of Peptidase M84. We observed that Peptidase M84 induced PAR-1 overexpression along with activating its downstream signaling effectors NF-κB and MAPK to promote excessive reactive oxygen species (ROS) generation. This evoked apoptotic death of the ovarian cancer cells through the intrinsic route. In in vivo set-up, weekly intraperitoneal administration of Peptidase M84 in syngeneic mice significantly diminished ascites accumulation, increasing murine survival rates by 60%. Collectively, our findings suggested that Peptidase M84 triggered PAR-1-mediated oxidative stress to act as an apoptosis inducer. This established Peptidase M84 as a drug candidate for receptor mediated targeted-therapy of ovarian cancer.

Intranasal immunization of mice with chimera of Salmonella Typhi protein elicits protective intestinal immunity.

Development of safe, highly effective and affordable enteric fever vaccines is a global health priority. Live, oral typhoid vaccines induce strong mucosal immunity and long-term protection, but safety remains a concern. In contrast, efficacy wears off rapidly for injectable, polysaccharide-based vaccines, which elicit poor mucosal response. We previously reported Salmonella Typhi outer membrane protein, T2544 as a potential candidate for bivalent (S. Typhi and S. Paratyphi A) vaccine development. Here, we show that intranasal immunization with a subunit vaccine (chimera of T2544 and cholera toxin B subunit) induced strong systemic and intestinal mucosal immunity and protection from S. Typhi challenge in a mouse model. CTB-T2544 augmented gut-homing receptor expression on lymphocytes that produced Th1 and Th17 cytokines, secretory IgA in stool that inhibited bacterial motility and epithelial attachment, antibody recall response and affinity maturation with increased number of follicular helper T cells and CD4+ central and effector memory cells.

A candidate glycoconjugate vaccine induces protective antibodies in the serum and intestinal secretions, antibody recall response and memory T cells and protects against both typhoidal and non-typhoidal Salmonella serovars.

Human Salmonella infections pose significant public health challenges globally, primarily due to low diagnostic yield of systemic infections, emerging and expanding antibiotic resistance of both the typhoidal and non-typhoidal Salmonella strains and the development of asymptomatic carrier state that functions as a reservoir of infection in the community. The limited long-term efficacy of the currently licensed typhoid vaccines, especially in smaller children and non-availability of vaccines against other Salmonella serovars necessitate active research towards developing a multivalent vaccine with wider coverage of protection against pathogenic Salmonella serovars. We had earlier reported immunogenicity and protective efficacy of a subunit vaccine containing a recombinant outer membrane protein (T2544) of Salmonella Typhi in a mouse model. This was achieved through the robust induction of serum IgG, mucosal secretory IgA and Salmonella-specific cytotoxic T cells as well as memory B and T cell response. Here, we report the development of a glycoconjugate vaccine, containing high molecular weight complexes of Salmonella Typhimurium O-specific polysaccharide (OSP) and recombinant T2544 that conferred simultaneous protection against S. Typhi, S. Paratyphi, S. Typhimurium and cross-protection against S. enteritidis in mice. Our findings corroborate with the published studies that suggested the potential of Salmonella OSP as a vaccine antigen. The role of serum antibodies in vaccine-mediated protection is suggested by rapid seroconversion with high titers of serum IgG and IgA, persistently elevated titers after primary immunization along with a strong antibody recall response with higher avidity serum IgG against both OSP and T2544 and significantly raised SBA titers of both primary and secondary antibodies against different Salmonella serovars. Elevated intestinal secretory IgA and bacterial motility inhibition by the secretory antibodies supported their role as well in vaccine-induced protection. Finally, robust induction of T effector memory response indicates long term efficacy of the candidate vaccine. The above findings coupled with protection of vaccinated animals against multiple clinical isolates confirm the suitability of OSP-rT2544 as a broad-spectrum candidate subunit vaccine against human infection due to typhoidal and non-typhoidal Salmonella serovars.

Subtilisin from Bacillus amyloliquefaciens induces apoptosis in breast cancer cells through ubiquitin-proteasome-mediated tubulin degradation.

To search for novel proteases from environmental isolates which can induce apoptosis in cancer cells, we have purified subtilisin from Bacillus amyloliquefaciens and studied its anti-cancer properties. Subtilisin induced apoptosis in colon (HT29) and breast (MCF7) cancer cells but showed no effect on mouse peritoneal macrophages and normal breast cells (MCF10A). Western blot analysis showed that Bax, Bcl-2 level remained unchanged but tubulin level decreased significantly. Subtilisin does not induce the intrinsic pathway of apoptosis, rather it induced tubulin degradation in MCF-7 cells, whereas in normal cells (MCF-10A) tubulin degradation was not observed. Subtilisin activates ubiquitination and proteasomal-mediated tubulin degradation which was completely restored in presence of proteasome inhibitor MG-132. We further observed PARKIN, one of the known E3-ligase, is overexpressed and interacts with tubulin in subtilisin treated cells. Knockdown of PARKIN effectively downregulates ubiquitination and inhibits degradation of tubulin. PARKIN activation and tubulin degradation lead to ER-stress which in turn activates caspase-7 and PARP cleavage, thus guiding the subtilisin treated cells towards apoptosis. To our knowledge this is the first report of subtilisin induced apoptosis in cancer cells by proteasomal degradation of tubulin.

Macrophage Cell Lines and Murine Infection by Salmonella enterica Serovar Typhi L-Form Bacteria.

Antibiotic resistance of pathogenic bacteria has emerged as a major threat to public health worldwide. While stable resistance due to the acquisition of genomic mutations or plasmids carrying antibiotic resistance genes is well established, much less is known about the temporary and reversible resistance induced by antibiotic treatment, such as that due to treatment with bacterial cell wall-inhibiting antibiotics such as ampicillin. Typically, ampicillin concentration in the blood and other tissues gradually increases over time after initiation of the treatment. As a result, the bacterial population is exposed to a concentration gradient of ampicillin during the treatment of infectious diseases. This is different from in vitro drug testing, where the organism is exposed to fixed drug concentrations from the beginning until the end. To mimic the mode of antibiotic exposure of microorganisms within host tissues, we cultured the wild-type, ampicillin-sensitive Salmonella enterica serovar Typhi Ty2 strain (S. Typhi Ty2) in the presence of increasing concentrations of ampicillin over a period of 14 days. This resulted in the development of a strain that displayed several features of the so-called L-form of bacteria, including the absence of the cell wall, altered shape, and lower growth rate compared with the parental form. Studies of the pathogenesis of S. Typhi L-form showed efficient infection of the murine and human macrophage cell lines. More importantly, S. Typhi L-form was also able to establish infection in a mouse model to the extent comparable to its parental form. These results suggested that L-form generation following the initiation of treatment with antibiotics could lead to drug escape of S. Typhi and cell to cell (macrophages) spread of the bacteria, which sustain the infection. Oral infection by the L-form bacteria underscores the potential of rapid disease transmission through the fecal-oral route, highlighting the need for new approaches to decrease the reservoir of infection.

Identification of patients at high risk of fragility fractures in an Indian clinical setting using FRAX.

A case-control study was done to decipher whether the FRAX tool was useful in India. Several values around the mean and median of the FRAX score of the case group were assessed to calculate sensitivity, specificity, positive predictive value, negative predictive value, Youden's index and odds ratio, and to detect high-risk individuals. PURPOSE: The Fracture Risk Assessment Tool (FRAX) appears useful to diagnose fragility fractures. The study aims to answer whether the FRAX tool has utility in India. METHODS: One hundred ten cases with a history of recent fragility fractures and 84 controls with no fractures were included in the study. FRAX scores without bone mineral density (BMD), and also with it, of participants were calculated. Several cutoff FRAX scores were chosen around mean and median FRAX score of cases. The odds ratio was calculated along with sensitivity, specificity, positive predictive value, negative predictive value and Youden's index. The most ideal cutoff was chosen to construct a hypothetical model to detect individuals at high risk. RESULTS: The FRAX score with BMD and without BMD exhibited relatively high specificity and moderate to low sensitivity implying that FRAX scores above cutoff have diagnostic value. Cutoffs at which FRAX score without BMD exhibited high specificity (> 90%) were chosen to construct a hypothetical model. Patients with FRAX score without BMD in the intermediate range be advised dual-energy X-ray absorptiometry (DEXA) followed by recalculation of FRAX score with BMD. DEXA scan T score less than - 2.5 or FRAX score with BMD above the cutoff at which specificity was high (> 80%) were included to construct the hypothetical model. Patients with low FRAX score could be followed up. The hypothetical model was applied to the case group to analyse its detection potential. CONCLUSION: FRAX has utility in India. It cuts the cost of screening and limits the use of expensive investigation.

Assessment of risk factors and occurrence of osteoporotic fractures among low impact trauma clients in West Bengal, India

OBJECTIVE: Management of osteoporotic fractures becomes challenging because of its multiple associated factors as well as poor bone quality. Therefore, assessments of the risk factors of osteoporotic fractures among low impact trauma client is a matter of great concern which can be addressed properly to reduce their occurrence in future. METHOD: Thirty patients with single or multiple fractures were selected purposively for descriptive survey study between January 2018 to December 2018. Their ages varied from 41 to 80 years. There were 26 female and four males. 24 patients have single fracture and six had multiple fractures following low impact trauma. The demographic parameters were studied by structured interview schedule, and the research variable, the risk factors were studied by interview, biophysical assessment and records of BMD value through DEXA and serum level of vitamin D. Socio-demographic variables like age, sex, body weight, Body mass index (BMI), etc. were selected and their relationship were assessed to find out the risk factors of fragility fractures in society by research variables like risk factors of osteoporotic fractures. For statistical analysis of determination of association between such factors and fragility fractures, non-parametric Fisher exact test and Odds ratio was used. RESULTS: In our study, osteoporotic fractures occurred majority (86.66%) among female maximally among 60-69 years age group. Whereas in relatively younger age (40-60 years), abnormal BMI (low or high) is responsible for fragility fracture as 46.6% of such fractures occurred in this group as 20% fracture are associated with underweight and 40.66% with overweight BMI. Tobacco smoking increases the risk of fragility fractures twice (as relative risk ratio 2) and rheumatoid arthritis increases the six-fold (as relative risk ratio 6). All 100% had history of fall. Level of serum vitamin D, low DEXA scan value (less than −2.5) and fall on ground resulting in low impact injuries shows strong association between those and fragility fractures. On the other hand, all the risk factors remain same for the recent and old fractures. CONCLUSION: Several risk factors need to be addressed properly apart from medical managements to reduce the risk of occurrence of osteoporotic fractures

No disponible

Evaluation of Functional Outcome of Elbows after Resection Arthroplasty of Failed Total Elbow Replacement.

BACKGROUND: Recovery of elbow function is a challenging problem following resection arthroplasty after failure of total elbow prosthesis. The objective of this study is to evaluate long term functional outcome in a series of such patients. MATERIALS AND METHODS: Nineteen patients with twenty elbows who had failed total elbow arthroplasty (TEA) following the use of Baksi total elbow prosthesis needed removal of prosthesis during the period from 1978 to 2003. As two patients were lost to followup, 17 patients with 18 elbows (bilateral in one) were included in this study with a mean age of 44.3 years. Nine cases had uncontrolled infection, seven cases of aseptic loosening including one occurred after TEA for bilateral postburns ankylosis, and two had broken humeral stems. After removal of the prosthesis and its adjacent surrounding bone cement, the cut ends of humerus and ulna were approximated with number 5 Ethibond suture. Postoperatively, the elbow was immobilized in a plaster slab in 110° elbow flexion for 6 weeks followed by physiotherapy. The patients were evaluated for 15-19.4 (mean 16.3) years where functional results were compared at 10 years and 15 years following resection arthroplasty. RESULTS: The resected elbow initially remained flail but gradually regained stability, especially in the sagittal plane. Both the groups showed overall improvement from preoperative Mayo Elbow Performance Score (MEPS) 26.5 to postoperative mean MEPS at 10 years (69.6) and at 15 years (70) (P = 0.001). Postoperative mean DASH score was 36.62 at 10 years' and 36.38 at 15 years' followup, suggesting persistence of function of resected elbow in the passage of time. The results were good in 9 (50%), fair in 7 (38.8%), and poor in 2 (11.1%) patients. None had recurrence of infection. Transient ulnar nerve palsy was seen in three patients. Postoperatively, power of Biceps recovered up to Medical Research Council grade 4 and Triceps 2-3. CONCLUSION: Resection arthroplasty of elbow provided acceptable functional recovery in our series of patients with failed elbow prosthesis.

Salmonella Typhi outer membrane protein STIV is a potential candidate for vaccine development against typhoid and paratyphoid fever.

Enteric fever, caused by Salmonella enterica serovars, Typhi (S. Typhi) and Paratyphi (S. Paratyphi) is a major public health challenge for the developing nations. Globally, the disease affects ˜15-30 million individuals every year, resulting in >200,000 deaths. Multidrug-resistant S. Typhi H58 strain has emerged as the dominant circulating strain in a large part of the world and an extensively drug-resistant (XDR) subclade of the strain was recently reported. Many believe that vaccination of the susceptible populations is urgently needed and the best option to control the infection. However, the commercial live attenuated (Ty21a) vaccine is not recommended for children below six years of age while the Vi-polysaccharide-based vaccine has poor long-term efficacy against typhoid fever. Moreover, no vaccines are available against S. Paratyphi infection. Thus, a new formulation capable of providing long term protection against both the pathogens and safe for all age groups is immediately required. We show that recombinant, S. Typhi outer membrane protein STIV (rSTIV) is immunogenic in mice and elicits high serum titers of different immunoglobulin subtypes. STIV antibodies opsonize S. Typhi and S. Paratyphi A to promote antibody-dependent cellular cytotoxicity and complement-mediated lysis. Immunization with rSTIV also induces robust cell-mediated immunity, including antigen-specific T cell proliferation and cytotoxic T lymphocyte response. Finally, mice immunized with rSTIV are significantly protected against S. Typhi and S. Paratyphi A challenge, with reduced visceral bacterial load. Our results underscore the potential of rSTIV as a novel vaccine candidate for enteric fever.

Molecular targeting of breast and colon cancer cells by PAR1 mediated apoptosis through a novel pro-apoptotic peptide.

A novel activating peptide was designed and synthesized from V. cholerae hemagglutinine protease (HAP) mediated cleavage site of mouse PAR1. The peptide "PFISED" interacts with PAR1 in a new site which is different from its thrombin mediated conventional activation site and induced a series of new downstream signaling pathways. The peptide showed apoptosis in human and mouse breast (MCF-7 and EAC) and colon (HT29 and CT26) cancer cells where as in the same peptide concentration in normal human breast epithelial cells (MCF-10A), normal human fibroblast cells (MRC-5), normal mouse peritoneal macrophage cells and normal mouse breast and colon tissues did not show any effect. Treatment with this peptide enhanced the survival kinetics of EAC induced mice. The peptide mediated apoptosis was inhibited in presence of PAR1 inhibitor and was significantly reduced in si-PAR1 treated cells that indicate the activating peptide "PFISED" induced PAR1 mediated apoptosis of colon and breast cancer cells. This peptide induced over expression and activation of PAR1 and its downstream MAP kinase and NFκB signaling pathways. These signaling pathways enhanced the cellular ROS level to kill malignant cells. We report a novel pro-apoptotic peptide which can selectively kill malignant cells via its specific target receptor PAR1 which is over expressed in the malignant cells and can be used as a molecular target therapy for cancer treatment.

Anatomical variation of posterior slope of tibial plateau in adult Eastern Indian population.

BACKGROUND: Upper surface of the proximal tibial end, tibial plateau, has a slope directed posteroinferiorly relative to the long axis of the middle of the shaft. It has important consideration in surgeries such as knee arthroplasty, high tibial osteotomy, and medical imaging of the knee joint. The aim of the present study was to estimate the tibial plateau angle (TPA) by plain radiograph in the adult Eastern Indian population as during literature review, we were unable to find any study, except one (without specific reference axis), on this variable among the Indian population. MATERIALS AND METHODS: A sample was taken from adult patients attending the outpatient department of orthopedics of the institute with minor knee problems. Measurement of the TPA was done in the true lateral radiographs of the knee joints of the selected subjects by a standardized method. RESULTS: TPA varied widely from 6° to 24°, with the mean ± standard deviation value 13.6° ±3.5°. Student's unpaired t-test revealed no significant difference of TPA between left and right knees, both in male (P = 0.748) and female (P = 0.917) separately and in the entire study population irrespective of gender (P = 0.768). Comparison of TPA between male (13.3° ± 3.3°) and female (13.9° ± 3.4°) by Student's unpaired t-test showed no sexual dimorphism (P = 0.248). There were poor correlations of TPA with age and body mass index. CONCLUSION: The present study described the variations of the TPA in the adult Eastern Indian population (range 6°-24°, mean ± SD 13.6° ± 3.5°, no laterality, no sexual dimorphism, poor correlation with age and BMI). Knowledge of this study could be used in different orthopedic surgeries and imaging technique in or around the knee joint.

Evaluation of outcome of corrective ulnar osteotomy with bone grafting and annular ligament reconstruction in neglected monteggia fracture dislocation in children.

INTRODUCTION: Neglected Monteggia fracture dislocation in the paediatric age group constitutes significant disability in respect to pain, stiffness, deformity, neurological compromise and restriction of activities of daily living. MATERIALS AND METHODS: A longitudinal prospective study was done on 21 children with old Monteggia fracture-dislocation which included 18 cases of Bado type I and 3 cases of Bado type III at the department of orthopaedics, IPGME&R,SSKM hospital, Kolkata, India between 2007 and 2012. All were treated by modified Hirayama corrective osteotomy of ulna with wedge bone grafting along with restoration of its length and reconstruction of annular ligament using Bell Tawse method and fixation of radial head with transcapitellar Kirschner wire. Average follow up period was 5.5 years. RESULTS AND ANALYSIS: Results were evaluated on the basis of 100 point Mayo Elbow Performance Index, radiology and questionnaire. The mean postoperative increase in Mayo Elbow Performance Index score was 30 with average increase in the range of movement by 30o. In three cases, there was subluxation of radial head and in addition one had transient palsy of posterior interosseous nerve. Three cases showed distortion of the radial head which were insignificant functionally. Results of improvement in mean MEPI were analysed by chi-square test and was significant at 0 .01 level of significance. CONCLUSION: Study showed good results with modified Hirayama osteotomy with annular ligament reconstruction using Bell Tawse procedure which is a more biological option for restoration of elbow biomechanics.

Harvesting the free fibular graft: A modified approach.

BACKGROUND: The conventional technique of free non-vascularized fibular grafting is attended with some amount of morbidity and a long scar. We report a technique with little interference to the surrounding soft tissues to harvest more than one-third of whole length fibula. PATIENTS AND METHODS: Thirty four patients of average age 23.5 years (range 8 to 51 years) having various pathologies like simple bone cysts (n=9), fibrous dysplasias (n=6), giant cell tumors (n=7), fracture non-union (n=10) and aneurysmal bone cysts (n=2) were taken up for the study. The fibula were harvested by two separate incisions, 1 cm each at proximal and distal extent of proposed donor site for taking out of graft after elevating the periosteum circumferentially using a periosteum stripper. Compression bandage and above knee plaster immobilization was applied to reduce the dead space collection. RESULTS: The mean followup is 34 months. The patients were evaluated clinicoradiology. Thirty three patients showed good results. One patient had fair result due to delayed wound healing from hematoma which was treated surgically. CONCLUSION: The approach of harvesting fibula suggested by author reduces donor site morbidity and is safer than conventional approach.

Prosthetic replacement of elbow for intercondylar fractures (recent or ununited) of humerus in the elderly.

Forty-one patients with an intercondylar fracture of the humerus (21 recent and 20 ununited) were treated by total elbow arthroplasty using Baksi's recent version of the sloppy hinge from January 2003 to April 2009. Twelve were AO classification type C2 and nine were type C3 recent closed fractures of seven days' mean duration according to Muller classification. Patient's mean age was 64 years. There were 20 nonunions (nine untreated nonunions of a mean of 11 months duration and 11 following failed internal fixation of a mean of 14 months duration); mean patient age was 58 years. The follow up period was 12-88 (mean 55.5) months. Mean arc of postoperative elbow flexion was 25-130° obtained in 39 (95.1%) patients. Mean arc of 65° pronation and 60° supination was obtained in 33(80.5%) patients. According to the Mayo elbow performance score, in the fresh-fracture group, excellent results were seen in 19 (90.5%), good in one (4.8%), and failure in one (4.8%), whereas in the nonunion group, excellent results were obtained in 17 (85%), good in two (10%), and failure in one (5%). Failure in the two patients was due to deep infection requiring prosthesis removal. Other complications were transient ulnar neurapraxia in three, disassembly of the prosthesis in one, patchy heterotopic ossification in two and localised radiolucency around the flanges of the humeral stem in one.

Use of external fixator in trochanteric fractures of femur.

External fixation of trochanteric fractures appears to be an effective option where major surgery is contra-indicated. A total of 26 cases of trochanteric fractures of femur (12 stable and 14 unstable) were treated with external fixation as other conventional treatment could not be applied due to associated comorbid factors related specially with the elderly age group and those unsuitable for major surgery and open trochanteric fractures. Ages of the patients varied from 38 to 93 (average being 64.8) years. Sixteen patients were female and 10 were male. Right side was affected in 12 and left side in 14 cases. All the cases were operated either by short general or spinal anaesthesia or even under local anaesthesia. All fractures united within 14-18 (average 16) weeks of time. According to Salvatti and Wilson scoring 10 patients showed good, 8 patients fair and 2 patients poor results. Out of other 6 patients, 2 patients died during course of treatment and 4 patients did not turn up for follow-up. Six patients suffered from superficial and two from deep pin tract infections. Other complications were noted such as bed sores in 2, mild to moderate degree of stiffness of both hips and knee joints in 2 and shortening of the affected limb (avarage 2 cm) in 17 cases. This procedure may be recommended to any patient with trochanteric fracture, who are unfit for major surgery and also for open fractures.

Long-term results of decompression and muscle-pedicle bone grafting for osteonecrosis of the femoral head.

In this paper, 152 patients with 187 osteonecrotic femoral heads (83 idiopathic, 56 corticosteroid induced, 40 post-traumatic, seven alcohol abuse and one associated with gout) were classified according to the staging by Ficat and Arlet (Ischemia and necroses of bone, Williams and Wilkins, Baltimore, Maryland, pp 171-182, 1980); four were in Stage I, 82 in Stage II and 101 in Stage III. The majority of the patients were young (average age 35.5 years). Multiple drilling, curettage of the necrotic bone and muscle-pedicle bone grafting using tensor fascia lata was carried out in all patients except in six adolescents, where sartorius grafting was performed. Cheilectomy of the femoral head and subcutaneous adductor tenotomy were also performed in the advanced stages. During the follow up of 10 to 21.5 years (average 16.5 years), radiological improvement was noted in 81.3% of patients in Stage II and 70.1% of patients in Stage III cases. Excellent and good results according to the Hospital for Special Surgery (HSS) score were obtained in 100% of cases in Stage I, 92% in Stage II and 80.4% in stage III, with a survivorship of 91% in Stage II and 82% in Stage III cases. The patients having an HSS score below 20 (non-survival) were recommended for total hip replacement (THR) therapy.

Deltoid contracture: a study of nineteen cases.

OBJECTIVE: Deltoid contracture is not uncommon in India. Contractures of deltoid often do not have definite etiology. We have critically analyzed the condition as regards the etiopathogenesis and its surgical results. MATERIALS AND METHODS: Nineteen patients with deltoid contracture operated between June 1990 and September 2001 were enrolled for a unicentric retrospective study. The surgery was indicated in patients with abduction deformity of more than 30 degrees at the shoulder. The etiology of deltoid contracture was idiopathic (n = 13) intramuscular injection in deltoid muscle (n = 5) and blunt trauma (n = 1). All were operated by distal release (incision near the insertion of the deltoid muscle). The average follow-up was of 9.5 years (range 6-17 years). They were evaluated based on parameters like pain, persistence of deformity, range of shoulder movements and strength of deltoid. RESULTS: All patients recovered painless full range of shoulder motion except one. The correction of deformity was achieved in all patients and there was no loss of strength of deltoid compared to the opposite side. Histology of excised tissue showed features of chronic inflammation. The complications observed were hypertrophic scar (n = 1), painful terminal restriction of shoulder movements (n = 1) and prominent vertebral border of scapula (n = 1). CONCLUSION: Deltoid contracture has features of chronic inflammation, and the intramuscular deltoid injection is the most incriminating factor in its etiopathogenesis. The condition can be effectively managed surgically by distal release of the deltoid muscle combined with excision of the muscular fibrotic contracture band.

Modified Boytchev procedure for the treatment of recurrent anterior dislocation of the shoulder.

From January 1990 to December 1998, 48 patients with 50 recurrent anterior dislocations of the shoulder were treated using a modified Boytchev procedure. The age of the patients varied from 18 to 35 years (average 24.7 years). The follow-up period was in average 88 (26-132) months. Six patients were lost in follow-up. Forty-two shoulders showed excellent results. There was one traction injury of the musculocutaneous nerve and one patient with immediate recurrence of the dislocation. Superficial wound infection occurred in five cases, all of which were controlled by antibiotics.