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Lumbosacral transitional vertebrae as a predisposing cause of cauda equina syndrome in German shepherd dogs: 161 cases (1987-1990).

The records of 161 German Shepherd Dogs were divided into groups depending on whether there was a radiographic diagnosis of degenerative disk disease (DDD) involving the lumbosacral disk and lumbosacral transitional vertebral segments (TVS) and whether the dogs had cauda equina syndrome (CES). Statistical analysis of the data suggested an association between TVS and CES and an association between DDD and CES. Establishment of confidence intervals revealed the group without either DDD or TVS indicators differed markedly from the other 3 groups of CES relative to the presence of DDD and TVS. There was some overlap in the confidence intervals, but the proportions of CES were higher when DDD and TVS were both evident. This suggests that the important clinical syndrome of CES is at least partially dependent on TVS, which is probably an inherited condition. Because German Shepherd Dogs have a higher frequency of TVS than dogs of other breeds, this partially explains the higher frequency of CES in this breed. Because TVS are probably familial, we suggest the presence of this lesion should be considered in selection of breeding stock. Although it is believed that DDD is partially dependent on the existence of TVS, it is known that DDD can develop in the absence of TVS.

Animals↗

[Reconstruction of post-traumatic diaphyseal bone loss by segmental bone transfer].

Until the beginning of the 1980s, reconstruction of major post-traumatic diaphyseal bone loss as an alternative to amputation was possible only by massive autologous bone grafts. Such a technique was limited by the amount of available bone required for grafting. Ilizarov explained the distraction osteogenesis principle and designed a circular external fixation material that was suitable for compression-extension. He described the concept of segmental bone transfer, which allows bone regeneration to take place within the actual injured limb. Our present experience is based on the literature and the study of 12 cases. All patients presented with significant post-traumatic tibial bone loss ranging from 45 to 145 mm. In this article, we discuss the indications, benefits and risks of such a technique compared to classic methods. Mainly indicated in patients who have sustained significant bone loss, bone transfer is the method of choice for preserving bone stock and correcting limb discrepancy, although it does not reduce consolidation time. Moreover, circular external fixations are often poorly tolerated and may be replaced by unilateral devices that are easier to install.

Diaphyses↗

Stability of fused versus nonfused THA femoral impaction grafts.

Impaction grafting for THA involves compacting morselized cancellous bone (MCB) into a cavitary defect to build up bone stock. Ideally, the MCB subsequently remodels into a new contiguous cancellous lattice. A recent laboratory model of MCB fusion allows simulating an impaction graft construct in this ideal eventual clinical state. The purpose of the present study was to determine the relative stability of femoral impaction graft constructs in which the MCB has fused versus that for MCB in the freshly impacted nonfused condition. Cemented femoral impaction graft constructs were created in composite femurs. For fused constructs, the MCB was mixed with an amine epoxy that causes the MCB to set up into a contiguous structure biomechanically comparable to intact cancellous bone in compression. The constructs were loaded with 500,000 physiologic gait cycles. Three-dimensional motion was measured between the femur and the stem. The fused femoral impaction grafts were much more stable than the nonfused grafts at the proximal stem location, but MCB fusion had only a modest effect on distal stem stability. These results indicate that most of the opportunity to reduce femoral stem micromotion and migration lies proximal, and that steps to enhance impaction graft remodeling and fusion are most effectively focused proximally.

Arthroplasty, Replacement, Hip↗

A comparison of the viscoelastic properties of bone grafts.

BACKGROUND: The expansion in joint arthroplasty surgery in the 1970s has resulted in a large group of patients who require revision arthroplasty for aseptic loosening. Impaction bone grafting to deal with bone stock loss has become an increasingly popular procedure in revision hip surgery. The results of this revision surgery are variable and very much dependent on the grafting techniques adopted at the time of surgery. In vitro testing of impaction bone grafting methods can constitute an important tool to improve long-term clinical results. The increasing clinical demand for human allograft limits its availability for use in in vitro laboratory studies therefore suitable experimental alternatives are required. METHODS: Human, porcine and ovine cancellous bone grafts were morsellised and prepared for in vitro laboratory testing following a standard operative technique. Each graft type was compressed using a die plunger test. After compression to a predetermined level the graft was left to relax for 120s. A comparison of the compression moduli and of the relaxation characteristics for each graft preparation was performed. In addition, the effects of washing the graft and of cartilage removal from the graft mixture were investigated. RESULTS: This study has demonstrated that there is no statistical difference in the compression modulus or relaxation percentage between human and ovine graft preparations. The effect of removing cartilage and washing the graft mixtures were inconsistent with regard to alterations in the viscoelastic properties of the grafts. INTERPRETATION: On the basis of the experiments performed we recommend the use of ovine bone graft as a suitable substitute for human allograft for in vitro testing of impaction bone grafting methods. The properties of ovine graft were similar for both compression moduli and relaxation properties to human allograft.

Animals↗

The apparent elastic modulus of the juxtarticular subchondral bone of the femoral head.

An experiment was undertaken to obtain approximate values for the intrinsic elastic modulus of subchondral bone. Shallow spherical caps, with uniform and incrementally controlled thickness, were machined from subchondral bone in the weight-bearing regions of 11 fresh-frozen normal femoral head autopsy specimens. Under application of polar point loads, the measured deflections were compared with a corresponding analytical shell solution, thus allowing back-calculation of the apparent modulus. Analogous tests were performed on similarly shaped specimens of stock Plexiglas of known modulus in order to estimate the precision of the testing method. The aggregate results for subchondral bone showed that its intrinsic stiffness correlated inversely with nominal shell thickness, but even the thinnest (1.0 mm thick) of these shells had an apparent modulus (mean = 1.372 GN/m2, SD = 414 MN/m2) well below that generally accepted for "pure" cortical bone (about 14 GN/m2). This stiffness deficit was very likely due to the presence of histologically evident marrow spaces. However, the low apparent modulus values measured in this study may not be fully representative of complex in vivo behavior, because in the testing of excised shells there is no radial compressive stress transfer to underlying cancellous bone.

Cartilage, Articular↗

Blindness in goats following ingestion of Stypandra glauca.

Twenty-seven of 427 Angora goats of mixed age became blind within a week of consuming large amounts of Stypandra glauca ("nodding blue lily"). A further 200 goats were depressed for several weeks, but most subsequently recovered. Blindness was associated with optic nerve neuropathy which is postulated to have followed compression of the optic nerves within the bony optic canals as a result of severe myelin oedema. Histologically, the intracanalicular portion of the optic nerve was sclerotic, while the intracranial portion of the optic nerve and the optic tracts were degenerating. The retrobulbar portion of the optic nerve was relatively unaffected. In addition, multifocal retinal photoreceptor degeneration was found ophthalmoscopically and histologically. The syndrome was not reproduced during a trial in which 2 goats were fed 4 and 20 kg of S. glauca harvested after it had finished flowering, more than 3 weeks after the first natural cases of blindness. Based on epidemiological and pathological data we propose that S. glauca is toxic to stock, but only for a short period while flowering in spring.

Animals↗

Accuracy of displayed values of tidal volume in the pediatric intensive care unit.

OBJECTIVES: To assess the accuracy of the expired tidal volumes (VT(E)) displayed by one of the most frequently used ventilators that measures exhaled volume at the expiratory valve. DESIGN: Prospective study. SETTING: The intensive care units of a pediatric tertiary referral center in London, UK. PATIENTS: A total of 56 intubated children aged between 3 wks and 16.6 yrs who were clinically stable and ventilated with a Servo 300 ventilator. INTERVENTIONS: The CO2SMO Plus respiratory monitor, which measures flow at the airway opening, was validated using calibrated syringes and appropriate tracheal tubes and connections. Simultaneous in vivo recordings of VT(E) from the Servo 300 and CO2SMO Plus were compared before (displayed Servo VT(E)) and after (effective Servo VT(E)) compensating for ventilator circuit compliance. MEASUREMENTS AND MAIN RESULTS: The in vitro accuracy of the CO2SMO Plus was within +/-5% over a wide range of volumes and measurement conditions. The displayed Servo 300 VT(E) overestimated the true VT(E) by between 2% and 91%. The magnitude of error varied within and between children, according to pressure change (peak inspiratory pressure minus positive end-expiratory pressure), VT(E), and circuit size. Mean (sd) error was 32% (20%) in 40 children with displayed Servo VT(E) of <160 mL and 18% (6%) in 16 subjects with displayed Servo VT(E) of >/=160 mL. After correcting for gas compression, effective VT(E) from the Servo 300 underestimated the true VT(E) by up to 64% in the smallest infants but continued to overestimate by as much as 29% in older children. CONCLUSIONS: The accuracy of tidal volume values is crucially dependent on the site of measurement. Unless measured at the airway opening, displayed values are an inconsistent and misleading indicator of the true volumes delivered.

Adolescent↗

Restricted feeding in early and late-feathering chickens. 2. Reproductive responses.

Reproductive traits of females from a broiler-breeder parent stock segregating for early and late feathering were measured under four feeding regimens. Feeding regimens consisted of ad libitum (AL, feed was always available), ad libitum restricted (ALR, feed restricted daily to control body weight), and skip-one-day and skip-two-days (SOD and STD, given two or three times ALR allowance on Day 1 and not fed on the next 1 or 2 days, respectively). At 160 days of age, pullets on SOD and STD were changed to ALR feeding, and daily feed allowances were increased to 135 g by Day 180 and 138 g by Day 250. Early and late feathering chickens responded similarly, except that hen-day ovulation rates, relative egg shell weights, and incidences of extracalcified and compressed eggs were greater for the former than the later. For most traits measured, differences among restricted feeding regimens were minor, but considerable differences were noted between them and the AL regimen. Females fed AL reached sexual maturity approximately 60 days earlier than those whose feed intake was restricted. Also, body weights at onset of lay were about 1,200 g greater for AL than for feed-restricted females. Percentages of hen-day ovulation, normal egg production, and duration of fertility were lower, whereas incidence of defective eggs was higher for AL than for feed-restricted chickens.

Animal Husbandry↗

[Primary hemangiosarcoma as a rare form of an incidentally discovered mass of the adrenal glands].

A 50-year-old man with sudden onset of nausea, vomiting and diarrhoea was on ultrasonography of the upper abdomen found to have an adrenal tumour, 5.5 cm in diameter. This was excised transperitoneally with its connective-tissue pseudocapsule, there being no enlarged regional lymph nodes or other pathological findings. But the histological diagnosis was haemangiosarcoma of the adrenal. Seven months later the patient was re-admitted because of suspected acute cholecystitis. Emergency laparotomy revealed a gangrenous, stone-free gallbladder without abscess. Further exploration was not possible because of inflammatory changes and marked adhesions. Recurrent vomiting postoperatively indicated endoscopic retrograde cholangiopancreatography and computed tomography, which showed a space-occupying lesion in the right adrenal region with compression of the choledochal duct, lesser gastric curvature and duodenum. At re-laparotomy tumour recurrence was found with histologically proven intraluminal metastases of the haemangiosarcoma in the jejunum. As curative resection was not possible, a palliative gastrojejunostomy was performed. The patient died 9 months after the diagnosis had been made from the advanced malignancy. This case of a rapidly fatal very rare malignant adrenal tumour underlines the need to remove all hormone-active asymptomatic adrenal tumours 4 cm in diameter or larger.

Adrenal Gland Neoplasms↗

Internal fixation of femoral neck fractures: a prospective study.

To determine the adequacy of reduction and the soundness of the technique of primary internal fixation, the authors studied prospectively 96 femoral neck fractures over 6 1/2 years. Patients were followed up for an average of 11 months. The mean patient age was 70 years. Both clinical and radiologic data were collected at 3-month intervals for 6 months and then annually. Radiologic indices recorded included the Garden classification and index, shear angle, Western Infirmary Glasgow angle, lateral angle, nail placement, occurrence of bony union and presence of avascular necrosis. The fixation devices included sliding compression screw and side plate, multiple Knowles pins and a 130 degrees AO blade plate. A high rate of varus reduction, excessive ante- or retroversion and poor nail placement were all noted. Twenty-three patients required a total of 36 reoperations. There were six deaths in the first 6 months after operation. Eighty-five patients (mean age 79 years) with femoral neck fractures treated by hemiarthroplasty (71) or total hip replacement (14) during the same period were also reviewed. Follow-up averaged 8 months. Two patients required reoperation. The general morbidity was similar to that of the group treated by internal fixation, but there were eight deaths. Femoral neck fractures, if treated by internal fixation, demand accurate reduction and fixation for optimum results. Primary prosthetic replacement should be reserved for elderly patients with poor bone stock.

Aged↗

Endovascular venous stenting in May-Thurner syndrome.

BACKGROUND: Chronic pulsatile compression of the left common iliac vein between the crossing right common iliac artery and the lowest lumbar vertebral body may induce focal intimal proliferation of the vein (May-Thurner syndrome), resulting in impaired venous return and left iliofemoral thrombosis. Corrective surgical treatment requires extensive dissection. In this report, we describe our experience with endovascular venous stenting in May-Thurner syndrome. METHODS: Six patients with symptomatic May-Thurner syndrome were treated with percutaneous transluminal angioplasty and implantation of self-expanding stents. RESULTS Postprocedure phlebography revealed patent iliofemoral veins with unimpeded venous outflow and disappearance of collaterals in all patients. No procedure-related complications occurred. At follow-up (median, 12 months), 5 of 6 patients were free of symptoms. In one patient lower extremity edema was aggravated despite a patent stented segment of the left iliac vein. The patient continues to wear support stockings to compensate for continuing venous insufficiency. Color coded duplex scanning revealed patency at regular intervals in 5 patients. In one patient, occlusion of the stented venous segment with return of symptoms was detected at one month. Patency could not be restored despite catheter-directed thrombolytic therapy. After angioplasty, however, adequate collateral circulation was restored and symptoms resolved completely. CONCLUSIONS: Endovascular venous stenting in May-Thurner syndrome is technically feasible, and leads to reduction of symptoms in the majority of patients with high patency rates in the medium-term. This approach may prove to be a percutaneous alternative to surgical treatment.

Adult↗

[Phlebitis following travel].

The term of economy class syndrome has been used to describe the deep vein thrombosis which may follow air travel. The mechanisms suggested for this include tendency to clot formation in the legs secondary to the reduced venous return induced by the sitting position with direct compression of popliteal and femoral veins, and secondary to dehydration and haemo-concentration. However, these conditions are also observed with others means of transport. We describe 16 patients with deep vein thrombosis following travel by bus, car, truck and train. These 16 patients represent 3.4 percent of 465 patients with thromboembolism managed over a 52-month period in our department. All but one patients had one or more risk factors for deep vein thrombosis. The mean duration of the trip was 14.2 hours and the first symptom occurred less than a week after the journey in 75 percent of the patients. These first symptoms suggested deep vein thrombosis in 8, pulmonary embolism in 5, and deep vein thrombosis with pulmonary embolism in 3 patients. Regular non alcoholic drinks and regular walks seem to be sufficient to prevent deep vein thrombosis in the great majority of travellers. However, low dose heparin on a temporary basis or elastic stockings could be considered in high risk subjects.

Adult↗

Surgical management of severe cervical kyphosis with myelopathy in osteogenesis imperfecta: a case report.

STUDY DESIGN: A case of a 9-year-old child with Osteogenesis Imperfecta and severe cervical kyphosis associated with wedged vertebrae and progressive neurological deterioration is presented. OBJECTIVE: To highlight the difficulties in surgical management of this condition and to discuss the appropriate surgical approach. SUMMARY OF BACKGROUND DATA: This case demonstrates an unusual case of Osteogenesis Imperfecta with associated wedged vertebrae causing a quadriparesis. Surgical decompression and stabilization can be performed with resolution of symptoms even in this age group with the appropriate approach and implants. METHODS: A 9-year-old girl presented with progressive cervical kyphosis and quadriparesis. At the age of 3 years, she underwent posterior cervical fusion (C1-C6) for instability. Radiological and laboratory investigations confirmed the diagnosis of Osteogenesis Imperfecta, and radiographs of the cervical spine revealed a kyphotic deformity of 120 degrees . Magnetic resonance imaging and computerized tomography scans showed anterior cord compression attributable to wedged vertebrae at C3 and C4. Magnetic resonance imaging-angiography was performed before surgery to identify the anatomic position of the vertebral arteries. A modified anterolateral approach to the upper cervical spine was performed, and anterior C3 and C4 corpectomies with interbody cage and plate fixation were carried out. RESULTS: After surgery the patient made a full neurological recovery, and significant correction of the deformity was achieved and maintained at follow-up. CONCLUSIONS: Cervical kyphotic deformity in Osteogenesis Imperfecta is uncommon. Association of this condition with wedged vertebrae is rare. Surgical decompression of the upper cervical spine is a challenging problem in the presence of this deformity. Which surgical approach to use is controversial. There are difficulties exposing wedged vertebrae by a standard anterior approach, and hence we have used a modified anterolateral approach to address this surgical problem, because a posterolateral approach was impossible with the intervening vertebral arteries. Spinal stabilization in children with Osteogenesis Imperfecta and poor bone stock is a challenge. We have used a small diameter MOSS cage ("Harms mesh cage") with maxillofacial plate and screws to achieve stabilization and fusion.

Bone Plates↗

New concepts of coxofemoral joint stability and the development of a clinical stress-radiographic method for quantitating hip joint laxity in the dog.

From mechanical principles and postmortem observations of coxofemoral joints of dogs, a hydrostatic mechanism influencing hip joint stability was discovered. This discovery led to the development of a stress-radiographic positioning method to quantitate hip joint laxity in dogs. The method incorporated 2 views with the dog in supine position and hips at neutral flexion/extension angle: a compression view, with the femoral heads fully seated in the acetabula; and a distraction view, with the femoral heads at maximal lateral displacement. An index measurement method was formulated to quantitate the relative degree of joint laxity appearing in either the compression or distraction view. Clinical evaluation of 6 dogs was done to compare the compression/distraction method with the standard hip-extended radiographic method. Also, the stress-radiographic method was performed on 16-week-old Borzoi and German Shepherd Dogs to compare the characteristics of inherent hip joint laxity in these breeds. In all dogs tested, hip joint laxity was masked by the standard hip-extended view as indicated by a 2.5-fold improvement in sensitivity to hip joint laxity of the new method (P less than 0.00001). Moreover, the mean hip joint laxity of 16-week-old German Shepherd Dogs exceeded the mean hip joint laxity of Borzois by 79% (P less than 0.00001). Reports in the literature document the incontrovertible association of hip joint laxity to the development of hip dysplasia in dogs. We believe the ability to accurately quantitate hip joint laxity will provide key diagnostic and prognostic criteria for the selection of pet dogs, and more importantly, breeding stock.

Animals↗

[Rheumatoid arthritis of the wrist with adult onset].

The author reviews the consequences of rheumatoid synovitis of tendons and joints at the wrist, consequences which are different on the volar and dorsal aspects of the wrist. He refers to a modified Larsen classification to describe the consequences of instability in the radiocarpal (RC), midcarpal (MC) and radioulnar (RU) joints, both in the coronal and sagittal planes. A. On the volar aspect, tenosynovitis of the flexor tendons is frequent but may be difficult to diagnose. Synovitis in the carpal tunnel, although frequent, rarely results in compression of the median nerve; persistence of synovitis despite medical treatment is an indication to synovectomy. The latter may have to be extended into the palm and over the proximal phalanges, using the appropriate approach in the individual cases. Flexor tendon ruptures may occur, mostly of the flexor pollicis longus (FPL) and the flexor tendons to the index finger. Rupture of the FPL may be treated by a tendon graft or by arthrodesis of the i.p. joint. Rupture of the deep flexor tendon to the index may be treated by anastomosis to that of the medius; rupture of the superficial flexor tendon to the index may be treated similarly; rupture of both flexor tendons requires a tendon graft. B. On the dorsal aspect, the indications vary according to the stage of the disease. In Larsen's stage IV or V (destruction of one or more of the radiocarpal and intracarpal joints with navicular dislocation), arthrodesis or arthroplasty is indicated; the latter is ruled out however if extensor tendons are ruptured or the bone stock is insufficient. An original or modified Mannerfelt technique is used for arthrodesis, with the wrist in neutral or slightly extended position. Several wrist prostheses are available. Swanson's silastic implant has been discontinued; the Meuli, CFV, Biax, Trispherical, ATW, and GUEPAR prostheses have all been used with varying degrees of success. The choice between arthrodesis and arthroplasty is based on the severity of articular and tendon pathology, on uni- or bilateral involvement and on the condition of other joints, particularly in the upper limb. In less advanced stages, the author advocates using a combined operation with synovectomy of the extensor tendons and of the RC, MC and RU joints, relaxation by tendon transfers and Sauvé-Kapandji's technique; he stresses important technical points. The specific indications for radiolunate arthrodesis are discussed.

Adult↗

[Lymphedema: is there a treatment?].

More than hundred medical treatments for lymphedema have been described. This very high number shows the evidence of difficulties: lymphatics are very small vessels, under low pression and velocity respondent to spontaneous quiet lymphatic contractions. The treatments can be listed in 3 groups: 1) physiotherapeutic methods, increasing lymphatic flow: cold, field stimulation, manual lymph drainage, intermittent compression, heat; 2) drugs: venous agents (flavone, benzo-pyrone), and intraarterial lymphocytes injection, promoting lymphatic flow or increasing normal proteolysis by macrophages in order to remove trapped proteins from interstitial fluid; 3) surgical procedures subdivided in 2 groups: excisional techniques and bridging drainage techniques; radical or partial excision removes involved subcutaneous tissue, recently by the way of liposuction; Efforts to drain lymphedema by subcutaneous implants, pedical flaps, myocutaneous flaps, omental transposition and intestinal flaps are historical. Microsurgical lymphatic anastomosis to vein (nodo-venous then lymphovenous), and to lymphatic themselves are now performed: lymphatic collectors or venous autografts are interpositioned to by-pass lymphatic blockade with end-to end anastomosis. The free transplantation of a lymphatic flap with its own vascularisation from healthy inguinal nodes to axillary blockade is the last described procedure. Lymphatic anastomosis are not needed. Actually, physiotherapy is always first indicated. Benzo-pyrones are additive drugs. Excisional procedures concern monstruous lymphedema. Microsurgical bridging procedures can be attempted only for secondary lymphedemas. They could be of benefit if physiotherapy and elastic bandages, stockings or sleeves, could then be avoided. Studies assessing independently the efficiency of each procedure are needed.

Anastomosis, Surgical↗

[Materials for mouth protectors].

Taking into account the number of teeth which are yearly irreversible traumatised during sport activities, the general use of mouthguards would contribute positively to the prevention of dental injuries. Custom-made mouthguards are more comfortable to wear and offer better retention and protection than stock and mouth-formed mouthguards. Different kinds of materials are available on the market for the construction of mouthguards. A polyethylene-polyvinylacetate copolymer (EVA) is the most suitable material. EVA allows the inclusion of hard or soft layers within the mouthguard. The thickness of a mouthguard is important for the reduction of applied forces to teeth: energy absorption capacity increases with material thickness. Increased thickness however, is associated with a reduction of comfort. Therefore, it is important that dentists take the patients' wishes and demands on both comfort and protection into consideration. A description of the clinical and technical method for the construction of a custom made mouthguard is given.

Absorption↗

Analysis of forced expiratory maneuvers from raised lung volumes in preterm infants.

During recent years it has been suggested that forced expiratory measurements, derived from a lung volume set by a standardized inflation pressure, are more reproducible than those attained during tidal breathing when the rapid thoracoabdominal compression technique is used in infants. The aim of this study was to evaluate the feasibility of obtaining measurements from raised lung volumes in unsedated preterm infants. Measurements were made in 18 infants (gestational age 26-35 wk, postnatal age 1-10 wk, test weight 1.4-3. 5 kg). Several inflations [1.5-2.5 kPa (15-25 cmH2O)] were used to briefly inhibit respiratory effort before the rapid thoracoabdominal compression was performed. Conventional analysis of flows and volumes at fixed times and percentages of the forced expiration resulted in a relatively high variability in this population. However, by using the elastic equilibrium point (i.e., the passively determined lung volume, derived from passive expirations before the forced expiration) as a volume landmark, it was feasible to achieve reproducible results in unsedated preterm infants, despite their strong respiratory reflexes and rapid respiratory rates. Because this approach is independent of changes in expiratory time, expired volume, or applied pressures, it may facilitate investigation of the effects of growth, development, and disease on airway function in infants, particularly during the first weeks of life, when conventional analysis of forced expirations may be inappropriate.

Female↗