Two different prenatal imaging cerebral patterns of tubulinopathy.

To illustrate the prenatal cerebral imaging features associated with tubulinopathy, we report on five affected fetuses from unrelated families, with a de-novo heterozygous variant in a tubulin gene (TUBA1A, TUBB2B or TUBB3). We identified two distinct prenatal imaging patterns related to tubulinopathy: a severe form, characterized by enlarged germinal matrices, microlissencephaly and a kinked brainstem; and a mild form which has not been reported previously in the prenatal literature. The latter form is associated with non-specific features, including an asymmetric brainstem, corpus callosal dysgenesis, a lack of Sylvian fissure operculization and distortion of the anterior part of the interhemispheric fissure with subsequent impacted medial borders of the frontal lobes, the combination of which, in the absence of additional extracerebral anomalies, is highly suggestive of tubulinopathy. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Amniotic fluid embolism: A comparison of two classification systems in a retrospective 8-year analysis from two tertiary hospitals.

OBJECTIVE: Amniotic fluid embolism (AFE) is a rare life-threatening complication in obstetrics, but the diagnosis lacks a consensual definition. The objective of this study was to compare two different AFE classification systems by analysing the AFE cases from two university hospitals. MATERIAL AND METHODS: In this retrospective study, all patients with a strong suspicion of AFE between 2014 and 2021 at two university hospitals, LMU Women's University Hospital Munich, and Women's University Hospital Basel, were included. Patient records were checked for the ICD-10 code O88.1 (AFE). Diagnoses were confirmed through clinical findings and/or autopsy. The presence of the diagnostic criteria of the Society of Maternal foetal Medicine (SMFM) and the AFE Foundation (AFEF) and of a new framework by Ponzio-Klijanienko et al. from Paris, France, were checked and compared using Chi-square-test. RESULTS: Within our study period, 38,934 women delivered in the two hospitals. Six patients had a strong suspicion of AFE (0.015%). Only three of six patients (50%) presented with all the four diagnostic criteria of the SMFM/AFEF framework. All six patients met the criteria of the modified "Paris AFE framework". CONCLUSION: Using the "Paris AFE framework" based exclusively on clinical criteria can help clinicians to diagnose AFE, anticipate the life-threatening condition of the patient and prepare immediately for best clinical care.

Delivery room desaturations and bradycardia in the early postnatal period of healthy term neonates - a prospective observational study.

OBJECTIVE: It has been suggested that desaturations and bradycardia precede acute life-threatening events (ALTE) and that ALTE is more common in the delivery room than later in life. However, frequency, duration and severity of desaturations in the first hours of life and additional risk factors have not readily been studied. METHODS: Term neonates (n = 100) were monitored for the first two hours after birth by pulse oximetry. The impact of maternal and perinatal factors on the frequency and severity of desaturations (<85%) and bradycardia (<80/min) was evaluated. RESULTS: Desaturations were detected in 30%, prolonged desaturations in 25% of infants. Desaturations were observed significantly more often in infants born by planned Cesarean section (pCs) compared to other modes of delivery (pCs 20/49; others 10/51; p = .029). Desaturations were also more frequent in infants diagnosed with neonatal infection (NI) or infants born to a mother with gestational diabetes (GDM), although not significantly. No bradycardia <80/min was detected. CONCLUSIONS: In our collective 4% of healthy term neonates had prolonged, clinically relevant desaturations in the first hours after birth. The mode of delivery and maternal risk factors may increase the risk for these events. However, our cohort was too small to detect any ALTE or SIDS and determine potential risk factors for these events. Our data lay ground for a large-scale prospective trial to investigate whether the mode of delivery could be an indication for general pulse oximetry monitoring of newborn in the delivery room.

Experimental studies on the bridging hypothesis of anaphylaxis: haptenic determinants required to elicit immediate-type reactions in calf skin by separate or concurrent sensitization with reagins of different specificity.

The present study has established, that cows suitably immunized with either DNP-edestin (DNP-Ed), di-DNP-gramicidin-J [(DNP)(2)-Gram], respectively, or p-azobenzenearsonate-Ed (ABA-Ed) synthesized and secreted reaginic antibodies (IgE) into colostrum. Whereas ABA-Ed failed to elicit more than a low response, there was however a persistent and increased antibody synthesis between 10 and 56 days after priming with DNP-Ed. Bivalent and multivalent DNP haptens differing in molecular size, degree of substitution, and rigidity were compared for their effectiveness in eliciting Prausnitz-Küstner (P-K) reactions in either newborn colostrum-deprived calves or in those 4 wk of age. The sensitization with reaginic anti-DNP antibody has been accomplished either by feeding colostrum of the immunized dam or by intradermal injection of reaginic serum or colostral whey. It could be demonstrated that equimolar doses of the bivalent alpha,N-(epsilon,N-DNP-aminocaproyl-)-epsilon,N-DNP-L-lysine and the multivalent dinitrophenylated bovine serum albumin were equally effective in eliciting reactions in skin sites provided that a high affinity antibody was used for sensitization. By contrast, the comparatively rigid, bivalent hapten, (DNP)(2)-Gram consistently failed to induce comparable reactions. Furthermore, it was clearly shown that optimal distances of determinant groups on the haptenic molecule are a prerequisite for positive P-K reactions, since alpha,epsilon,N-bis-DNP-lysine failed to induce comparable reactions. Concurrent sensitization of skin sites with reaginic anti-DNP and anti-ABA antibodies provides the final proof that cross-linking of two adjacent reaginic molecules on the mast cell surface by a bivalent hapten is required for effective elicitation of immediate-type reactions. This has been accomplished by utilizing the bivalent epsilon,N-DNP-alpha,N-[(4-hydroxy-3-azobenzenearsonic acid)-phenacetyl]-L-lysine (DNP-ABA) carrying noncross-reactive haptenic groups, which was consistently effective in eliciting P-K reactions in doubly but never in singly sensitized skin sites. It is apparent from the results that equimolar doses of monovalent haptens could completely inhibit the response to DNP-ABA. The present studies finally establish that mast cells of newborn colostrum-deprived calves lack IgE molecules on their surface. Thus, mast cells of newborn calves may be unique, to investigate the molecular mechanisms involved in immediate-type reactions more precisely.

The mechanically stable steam sterilization of bone grafts.

Bone allografts are the standard material used in augmentative bone surgery. However, steam-sterilized bone has a low mechanical stability and limited ossification based on low strain-adapted bone remodelling. Here we describe a new technique which allows the bone to be autoclaved without losing its mechanical stability and osteoconductivity. The compression strength of the new material was compared with steam-sterilized and fresh bone based on mechanical testing using bone cylinders (n=30/group). Allogeneic new material and fresh bone were press-fit implanted into rabbit patellar grooves and examined under fluorescent light and conventional microscopy. Initial healing was assessed after 30 d (n=5/group). Osseous integration and remodelling was studied after 100 d (n=12/group). Steam-sterilized bone showed no mechanical stability, whereas the new material was stiff and had compression curves similar to fresh bone; both groups showed equal degrees of direct ossification after 30 d, advanced bony ingrowth and remodelling after 100 d, and similar ingrowth depths on histomorphometric analysis. The new method preserved the stiffness and osteoconductivity of bone after steam sterilization, and microstructure, mineralization, and composition were conserved. This technique could be useful for bone banking in Third World countries.

Shock wave permeabilization with ribosome inactivating proteins: a new approach to tumor therapy.

Extracorporeal shock waves are high-pressure pulses of microsecond duration clinically used for lithotripsy. Recently, shock waves been shown to cause a transient increase of the permeability of the cell membrane. We therefore hypothesized that shock waves might be able to transfer tumoricidal agents into tumor cells and examined this in vitro and in vivo. In vitro, the ribosome inactivating proteins gelonin and saporin were transferred into L1210, SSK2, and HeLa cells, and dose-response curves were established. The drug concentration that reduced the cell proliferation by 50% (IC50) was assessed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, and the enhancement factors from shock wave application were calculated. It was found that shock waves enhanced the action of gelonin from 900-fold in L1210 cells to 40,000-fold in HeLa cells and the action of saporin from 300-fold in L1210 cells to 15,000-fold in HeLa cells. In vivo, the effect of gelonin and saporin was assessed in a murine tumor model. SSK2 fibrosarcoma tumors locally grown in C3H mice were treated with shock waves after i.p. administration of gelonin or saporin. Shock wave application delayed the tumor growth, and long-term remissions lasting >180 days were induced in 40% of the animals. In conclusion, shock waves enhanced the action of ribosome inactivating proteins and led to complete tumor remissions. The local transfer of toxic substances by shock waves into tumors constitutes a new approach to a local tumor therapy.

Shock waves: a novel method for cytoplasmic delivery of antisense oligonucleotides.

Intracytoplasmic delivery of oligonucleotides (ODN) can improve ODN-based strategies such as the antisense approach and the use of immunostimulatory CpG dinucleotide containing ODN. Shock waves are established for the treatment of nephrolithiasis and other diseases. Here we describe the use of shock waves as a new physical method for the direct transport of antisense ODN into the cytoplasm and the nucleus of cells. Human peripheral blood mononuclear cells together with antisense ODN were exposed to shock waves generated by an electrohydraulic lithotripter. ODN uptake was examined by flow cytometry and fluorescence microscopy. By optimization of physical parameters we achieved the transfer of high amounts of ODN which were detected within less than 5 min after shock wave exposure, with viability of cells higher than 95%. Transfection of human peripheral blood mononuclear cells with an antisense ODN directed against tumor necrosis factor (TNF) alpha resulted in a reduction in lipopolysaccharide-induced TNF production by 62% (n=5, P=0.006). Specificity of TNF suppression was confirmed with a four-mismatch oligonucleotide. Positive atmospheric pressure abolished antisense-mediated inhibition of TNF synthesis by blocking shock wave-induced cavitation and formation of oscillating air bubbles. Electroporation was less effective. The use of shock waves is thus an efficient physical tool for ODN delivery to cells. Shock waves may allow the evaluation of target proteins in cell types difficult to transfect with other methods and thus may improve the antisense technique for the analysis of unknown genes.

Acidic "peptidophospholipids", a new class of hapten-bearing cell surface modifying reagents.

Covalent coupling of glutamyl-glutamic acid to the amino group of ether-phosphatidylethanolamine (EPE) yields an acidic "peptidophospholipid" (Glu2-EPE) which is water-soluble above pH 7.0 and stable to phospholipase A. The terminal amino group of Glu2-EPE is free for coupling with amino-reactive determinants. We describe the synthesis of various hapten-substituted peptidophospholipids as well as of an intermediate compound, coupled with the heterobifunctional reagent 3-(2'-pyridyl)-dithiopropionic acid N-hydroxysuccinimide ester. The latter derivative allows binding to sulfhydryl-containing molecules, e.g. peptides or proteins. So far, beef and pig insulin as well as trinitrophenyl-substituted ribonuclease A have thus been linked to Glu2-EPE. All derivatives of Glu2-EPE are water-soluble at physiological pH and readily adsorb to cell surfaces from aq. solution. Binding to cells is fast, stable and "non-toxic" over a wide range of concns. The adsorbed determinants are accessible to specific antibodies and facilitate complement-mediated cell lysis. Glu2-EPE thus appears to be a universal carrier molecule for fast, simple and mild modification of cells with foreign determinants, e.g. for Jerne plaque assays.

Presentation of insulin and insulin A chain peptides to mouse T cells: involvement of cysteine residues.

The requirements for insulin presentation and recognition by A alpha b A beta b- and A alpha b A beta k-restricted mouse T cells were studied using a variety of derivatives of the insulin A chain. It was found that A chain peptides with irreversibly blocked Cys residues are non-stimulatory for the T cells. This suggests that at least one of the Cys residues is essential for recognition. On the other hand, all A chain peptides containing Cys residues modified in a way reversible by reaction with thiols are stimulatory yet differ in antigenic potency. All these A chain derivatives including a 14 amino acid fragment require uptake by antigen presenting cells (APC) for efficient presentation. Differences in stimulatory potency between the A chain peptides derived from the same insulin appear to be mainly due to the efficiency of uptake and/or processing by APC. Based on these findings we propose that processing in the case of insulin and its A chain derivatives involves the reductive deblocking of Cys residues or the rearrangement of disulfide bonds apart from a possible proteolytic cleavage. The same may apply to other proteins if Cys residues in the presented peptides are important for the interaction with Ia or the T cell receptor.

In vitro cytotoxic activity of lithotripter shock waves combined with adriamycin or with cisplatin on L1210 mouse leukemia cells.

The effect of a combined treatment with shock waves generated by a lithotripter and Adriamycin or cisplatin was examined in cells that acutely survived exposure to shock waves and proliferated afterwards. Batches of 2 x 10(6) cells were exposed to the respective drug for 50 min or for 50 min plus 72 h. During the 50-min drug exposure 500 shock waves were applied at 25 kV. The growth as a percentage of the control was determined after 72 h by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. Cells treated with shock waves alone showed a growth inhibition as compared to control cells. For a 50-min drug exposure with Adriamycin the dose enhancement ratio did not exceed 1.3. For a 50-min drug exposure with cisplatin at concentrations of 0.5 micrograms/ml and 5.0 micrograms/ml, growth (as a percentage of the control) after combined treatment was significantly reduced as compared to cisplatin treatment alone; the dose enhancement ratio was 3.2 at 50% growth compared to the control. This indicates that shock waves can increase the susceptibility of L1210 cells to cisplatin. For a 50-min plus 72-h drug exposure no effect of an additional treatment with shock waves, as compared to chemotherapy alone, could be observed.

Minimal static excess pressure minimises the effect of extracorporeal shock waves on cells and reduces it on gallstones.

The effects of extracorporeal shock waves on haemoglobin release, membrane permeabilisation and stone fragmentation were examined at minimal static excess pressures. Shock waves from an electrohydraulic lithotripter were applied at 15, 20 and 25 kV to red blood cells in plastic pipettes pressurised with 0, 30, 50, 75, 100, 200, 300 and 400 kPa of static excess pressure; the freed haemoglobin was determined as a marker of cell destruction. Using 15-kV discharges, 30-kPa excess pressure reduced the freed haemoglobin from 1.21 g/L at ambient pressure to 0.39 g/L, 20-kV discharges reduced it from 2.01 g/L to 0.92 g/ L and 25-kV discharges from 2.56 g/L to 1.61 g/L. Haemoglobin values at 400-kPa excess pressure were reduced to 0.03 g/L (15-kV discharges), 0.07 g/L (20-kV discharges) and 0.09 g/L (25-kV discharges), which is a 95%-97% reduction of the values obtained at ambient pressure. There was a steep initial drop from 30-100 kPa excess pressure followed by a plateau at low level. Propidium iodide uptake by L1210 tumour cells, a marker for transient membrane permeabilisation by shock waves, was reduced by 90% at these slight excess pressures. Stone fragmentation was also suppressed by excess pressure yet not as markedly as at cells; 100 kPa reduced the amount of gallstone fragments by 20%, and 400 kPa reduced it by 65%. A further reduction, by 93%, was obtained when 1-MPa excess pressure was applied to gallstones in a Plexiglas cylinder. Shock wave-gas bubble interaction has been previously proposed to mediate the shock wave action. It is suggested that the excess pressure reduced the size or number of the bubbles, thus reducing this interaction, at least in the case of the cellular effects. The reduced effect of shock waves on cells, in contrast to the effect on stones, might open up a new approach to the design of lithotripters that would reduce tissue damage yet keep fragmentation up at a similar level.

Influence of dissolved and free gases on iodine release and cell killing by shock waves in vitro.

Exposure of a potassium iodide solution to lithotripter shock waves resulted in formation of iodine with the amount of iodine depending on the gas dissolved in the solution. Iodine yield was higher with O2 and Ar, as compared to CO2 and N2O; degassed solution revealed the lowest iodine yield. Exposure of L1210 mouse leukemia cells to shock waves reduced the number of viable cells with no difference between O2-, Ar-, or N2O-equilibrated and degassed conditions. CO2 equilibration resulted in a more pronounced reduction. The difference between chemical and biological effects argues against the involvement of free radicals in cell killing by shock waves. In additional experiments, gas bubbles of various sizes were introduced into the test vials. Addition of a 10 microL gas bubble revealed an over 10-fold increase in iodine yield from degassed potassium iodide solution with all gases. Addition of a gas bubble also reduced the number of viable cells again with no difference between the gases. It is suggested that shock wave-gas bubble interaction is an important mediator of iodine release and cell killing by shock waves.

Extracorporeal shock waves act by shock wave-gas bubble interaction.

The effect of extracorporeal shock waves on hemoglobin release from red blood cells was recently found to be minimized under minute static excess pressure. It was proposed that this can be explained by shock wave-gas bubble interaction. We substantiated this further by two experiments by applying shock waves to suspended human RBC in a lithotripter at a lower frequency (1 pulse every 5 s) and by administering just a single or 2 strong shock waves at 30 kV. Compared to the usual application rate of 1 discharge per s, the lower frequency reduced the hemoglobin release under minimal static excess pressure in the range from 0-100 kPa. A single strong shock wave released a small amount of hemoglobin at ambient pressure and a similar amount at 200 kPa excess pressure. Two strong shock waves increased the hemoglobin release considerably at ambient pressure when there was a 1- or a 10-s pause between them. Under 200 kPa excess pressure, the hemoglobin release was minimal. A similar low hemoglobin release was also found with 1 shock at ambient and the other at excess pressure. The results are interpreted as clear evidence of shock wave-gas bubble interaction as a dominant mechanism of shock wave action.

Destruction of gallstones and model stones by extracorporeal shock waves.

The disintegration effectivity of an electrohydraulic lithotripter was evaluated by determining the acoustic energy that had to be applied, until all fragments of three artificial materials and human gallstones were cleared from a basket of 2.8 mm mesh size. The lithotripter had either an open ellipsoid, or the ellipsoidal axis was covered with a metal cage as used in clinical lithotripters to house the ultrasound scanner. Fragmentation was assessed at a low, medium and high voltage setting using 9 and 16 mm breeze block marbles, considered to be primarily fragmented by a cavitation-mediated mechanism; 16 mm glass marbles, considered to be primarily fragmented by a direct shock wave effect; 12 and 15 mm plaster balls as commonly used to monitor lithotripter output; and gallstones with a mean diameter of 16 mm. As a result, the acoustic energy for the disintegration of 9 and 16 mm breeze block marbles was 620 and 670 mJ cm-3, of glass marbles 3369 mJ cm-3, of 12 and 15 mm plaster balls 1599 and 1764 mJ cm-3 and of gallstones 8050 mJ cm-3. It was largely independent of pulse energy, specimen size and configuration of the shock wave source. It is concluded that acoustic energy is a major determinant of disintegration, independent of the presumed mechanism of destruction.

Biological effects of shock waves: cell disruption, viability, and proliferation of L1210 cells exposed to shock waves in vitro.

L1210 cells were exposed in suspension to shock waves generated with a Dornier XL1 lithotripter. After 1000 discharges at 25 kV, the number of nondisrupted cells was 15% and the number of trypan blue excluding cells was 7% as compared to 100% in sham treated controls; the shock-wave effect was more prominent at higher voltages and less prominent at higher discharge numbers when compared at similar electrical input energies. Overall proliferation of cells which were trypan blue negative after exposure exceeded 70% of the proliferation of sham treated controls, except after 1000 shocks at 25 kV, where proliferation was reduced to 42%. The latter reduction in proliferation was found to be due to a reduced growth for 24 h after exposure, with a return to normal proliferation during the following days. Limiting dilution analysis revealed that the reduced growth was mainly due to a transitory increase of the doubling time and not to a reduction of the number of proliferating cells. Cell disruption by shock waves was completely inhibited by exposing the cells at an elevated pressure of 101 atmospheres, pointing to the possible involvement of cavitation in the shock wave effect.

Acoustic energy determines haemoglobin release from erythrocytes by extracorporeal shock waves in vitro.

Haemoglobin release from erythrocytes by extracorporeal shock waves from an electrohydraulic lithotripter was quantified and correlated with the acoustic energy administered to the cell container. Cells were exposed in 2-, 5.9-, and 10.5-mL vials to 100 shock waves delivered at a low, medium and high lithotripter output setting, both with and without covering of the central ellipsoidal axis by a metal cage. Using the identical set-up, previous experiments had shown that the fragmentation efficiency was linearly correlated with the delivered acoustic energy. As a result, shock waves generated from 0.83 microgram mJ-1 (in 2-mL vials) to 1.53 micrograms mJ-1 (in 10.5-mL vials) haemoglobin. At all vial types, the amount of haemoglobin correlated linearly with the delivered acoustic energy (r = 0.96 in 2-mL, r = 0.97 in 5.9-mL and r = 0.98 in 10.5-mL vials). It was independent of the presence of the cage.

Biological effects of shock waves: induction of arrhythmia in piglet hearts.

During lithotripsy by electrohydraulic or electromagnetic lithotripters, the application of extracorporeal shock waves has to be synchronized with the electrocardiogram to reduce the induction of arrhythmias. The relation between the refractory period of the cardiac cycle and arrhythmia induction by shock waves, and the underlying mechanism have so far not been examined. In this experiment, the cardiac response to shock waves administered at 20 kV by an electrohydraulic lithotripter was assessed in nine piglets. The focus was positioned 5, 10 and 15 cm caudal to the apex of the left ventricle, and in some piglets also at the apex. The interval following the R-wave was determined during which the heart was refractory to shock wave stimulation by either single discharges or shock-wave bursts, i.e., groups of discharges separated by 10 ms intervals. This mechanical refractory period was compared to its electrical counterpart, which was determined by transvenous intracardiac atrial stimulation. As a result, mechanical refractory periods following the R-wave were at 5 cm distance 60 ms for single discharges and 70 ms for bursts (medians; range 10-180 ms); both stimulation modes were highly correlated (r = 0.88). While a similar result was obtained with the focus positioned directly at the cardiac apex, at 10 cm distance from it, bursts elicited a cardiac response significantly more often (in nine vs. two piglets). At 15 cm distance, no response was obtained at all. Both mechanical and electrical atrial refractory periods were in a similar range.(ABSTRACT TRUNCATED AT 250 WORDS)

Investigation of cavitation in flowing media by lithotripter shock waves both in vitro and in vivo.

Cavitation produced by lithotripter shock waves was characterized in vitro in water and blood, and in vivo in aortic blood by means of a 1.6 MHz resonant bubble detector. This system was readily able to detect bubbles resulting from shock-wave induced cavitation in both water and blood flowing through plastic tubes in vitro, and even in blood pumped by the heart through a plastic arterio-venous shunt. However, this system was unable to detect evidence of shock-wave induced cavitational activity occurring within the intact vascular systems of dogs in vivo.

Biological effects of shock waves: effect of shock waves on the liver and gallbladder wall of dogs--administration rate dependence.

The effect of extracoporeal shock waves on the liver and the gallbladder wall was compared in two groups of dogs exposed to 1500 shock waves generated in an electrohydraulic lithotripter with 15 kV and 80 nF. The waves were focused on the gallbladder wall. In the experimental group, a shock wave burst of 10 consecutive waves with an interval of 10 ms between the waves was administered each second; in the control group, single shocks were released each second. The day following shock wave exposure, the dogs were anaesthetized, killed and then dissected. In the liver, subcapsular and intraparenchymal focal haemorrhages occurred in the high pressure field and venous thrombi in portal veins. There was a nonsignificant trend towards an increased number of venous thrombi after burst application. The gallbladder wall was haemorrhagic and oedematous, the mucosa was ulcerated in the focal area; blood clots were found in nearly all gallbladders. No differences were detected between the groups. The free plasma haemoglobin was only increased after fast shock wave administration. Increased haemolysis and the trend towards an increased number of thrombi favour cavitation as a mechanism of shock wave damage. The similar extent of tissue damage suggests that shock wave bursts can be applied for gallstone destruction in humans if the major liver vessels are kept out of the high pressure field.

Biological effects of shock waves: in vivo effect of high energy pulses on rabbit bone.

Extracorporeal shock waves have recently been introduced to treat pseudarthrosis and aseptic bone necrosis. Only little information exists up to now about the morphological effects of shock waves on normal bone. To study both their acute effect on bone and their long-term effect on its remodelling, 1500 shock waves generated with a Dornier XL1 experimental electrohydraulic lithotripter were applied at 27.5 kV to 19 rabbits divided into five groups. Changes were evaluated after 6, 11, 41, 59 and 85 days. The discharges were focused to the right femur 1 cm above the knee joint. Bone remodelling was assessed in four groups by four-colour fluorescent labelling with labels administered sequentially over 8-day periods during the first month after shock-wave application. Radiographs were taken at dissection to detect fractures. As a result, shock waves were found to induce periosteal detachment with subperiosteal haemorrhages and to press marrow contents out of the medullary cavity. In the medullary cavity, diffuse haemorrhages, haematomas and foci of fractured and displaced bony trabeculae were found. The bone cortex and the knee joint were normal. Radiographs showed lucencies in the marrow but no fractures. During the weeks following shock-wave application, there was intense apposition of new cortical bone resulting in considerable cortical thickening while trabecular remodelling in the medullary cavity was only minor. The displacement of bony trabeculae and marrow contents point to the action of cavitation as the major mechanism of shockwave damage to bone.