Intracytoplasmic sperm injection of mouse oocytes with 5 mM Ca2+ at different intervals

The objective of this investigation was to determine whether intracytoplasmic sperm injection (ICSI) can be performed in the mouse. Metaphase II oocytes were obtained from F1 hybrid mice (C57BL x CBA) by i.p. injections of 10 IU pregnant mare's serum gonadotrophin (PMSG) and human chorionic gonadotrophin (HCG) administered 48 h apart. Oocytes with cumulus oophorus were retrieved 13-14 h post HCG. Cumulus was dispersed with 0.1% hyaluronidase. Mouse spermatozoa were obtained from the cauda epididymides of males of the same strain. The spermatozoa were processed by the standard swim-up procedure. The harvested spermatozoa were then incubated for 1.5 h to allow capacitation. Healthy oocytes were injected with 3-4 pl 5 mM Ca2+, followed by one live morphologically normal spermatozoon into the cytoplasm at intervals of 0, 0.5, 1, 2 and 3 h. The proportion of 2-cell embryos that developed from oocytes injected with Ca2+ and spermatozoa ranged between 29.5 and 36.5% in all groups, with no statistical difference between treatments. Chromosomal analysis showed that two-thirds of the ICSI-derived 2-cell embryos were diploid. The proportion of parthenogenetically activated embryos in the ICSI groups was similar to that in the control group (8-10%) which was injected with Ca2+ and polyvinyl pyrrolidone only. The proportion of blastocysts that developed in culture from the ICSI-derived 2-cell embryos was of the order of 36-42%. Some blastocysts were used for cell number counts. There was a significant increase in total and inner cell mass counts of blastocysts in which the spermatozoon was injected at 2 and 3 h following Ca2+.(ABSTRACT TRUNCATED AT 250 WORDS)

[Laser in surgery of vascular anastomoses]

The disadvantages of present-day microvascular suturing techniques include suture-induced foreign-body granulomas, stenoses and aneurysms. In comparison, argon laser-assisted anastomoses show a more favorable histomorphology and a low rate of stenoses and aneurysms. Laser-assisted anastomoses pass through the same familiar healing phases seen in common wound-healing.

Special problems in Fontan-type operations for complex cardiac lesions

Four patients with complex cardiac lesions, who underwent successfully a Fontan type of operation are presented, each case representing a particular problem in surgical management. The first exhibited displacement of a trileaflet straddling and overriding left atrioventricular valve in addition to tricuspid atresia, while the second one had unilateral lung perfusion. In the third case, a stenosis had developed near the origin of the right pulmonary artery, and pulmonary vascular resistance could not be determined prior to the definite palliation procedure, whereas the fourth patient presented with stenosis of the left atrioventricular valve. Surgery was planned after detailed evaluation of the morphologic and hemodynamic features by means of echocardiography and cardiac catheterization. Our results illustrate the common tendency to extend the limits for modified Fontan procedures, which also includes revision of the original criteria for selection.

[Wrist joint arthroscopy in obscure post-traumatic symptoms]

Clarification of posttraumatic wrist complaints is relatively difficult. Symptoms are often dismissed as wrist sprain. In an arthrogram a communication between the inferior radio-ulnar joint and the radiocarpal joint may indicate an injury of the triangular disc. In elderly patients, however, this communication can be present due to degenerative changes. Arthroscopy helps to evaluate not only the condition of the triangular disc, but also the cartilage of the distal forearm, the proximal carpal row, and some of the intercarpal ligaments. The authors report the results of wrist arthroscopy in twenty patients. Clinical and radiological examinations cannot always reveal the cause of disorders of the wrist. In these cases the procedure of arthroscopy can be recommended for preoperative clarification of cases of obscure posttraumatic wrist symptoms.

[Indications for replantation in psychiatric patients exemplified by hand replantation in a patient with schizophrenia]

After evaluating all criteria known about indications for replanting severed extremities, we found that mental retardation (with the exception of some conceivable isolated cases) and mental illness, i.e. psychosis, can no longer be considered absolute contraindications for replantation measures, due to the adequate therapeutic possibilities that are currently available.

[Determining indications and tactics in managing the severely injured hand]

The repair of a severely damaged hand requires not only a surgeon's skillful knowledge of the functional anatomy of the hand and the importance of its various parts and their place in the total function, but also experience in microsurgery. One's goal is to extensively save functionally important structures. Besides stabilizing the bone structure, microvascular measures to maintain blood circulation have priority. On the basis of three case studies each with different accident mechanisms, the problems of repairing a severely damaged hand and the results are described. When diagnosing such a severely damaged hand, one must evaluate the functional results that can be expected after repairing the hand in order to decide whether to keep it or to amputate and provide a prosthesis.

[Arthroscopic diagnosis of disk injury of the wrist joint]

Arthrography of the wrist joint is a possibility to show a disc lesion by demonstrating a communication between the radioulnar and -carpal space in cases of persistent wrist pain after an accident without any bone disorders in x-ray. For differentiation between a pre-existent disc variety with a central whole and a real traumatic tear or degenerative alterations arthroscopy is the method of choice. Furthermore other changes of the wrist as free bodies and chondropathy can be seen. The indication for an arthrotomy and a causal treatment are more exact and were proved by a follow-up of 10 patient between 1985-1987 at the orthopedic university clinic Berlin.

Successful palliation of the "absent" pulmonary valve syndrome by banding of the pulmonary trunk

The "absent" pulmonary valve syndrome is associated with aneurysmal dilatation of the pulmonary trunk, stenosis of the ventriculo-arterial junction with or without malalignment of the outlet septum, and ventricular septal defect. When the outlet septum is malaligned, the morphology resembles that of tetralogy of Fallot. We report our experience with 4 infants with this syndrome. All were in severe respiratory distress and cardiac failure when first seen. Cardiac catheterization was performed at 0.5-4.5 months of age in 3 of them. In the other, the clinical and echocardiographic features were considered sufficient to establish the diagnosis. Banding of the pulmonary trunk was carried out at the age of 2.5-5 months. The distal pulmonary arterial pressure in 3 cases dropped to 12-19 mm Hg. These patients could be extubated within one week postoperatively. Their course 1-3 years later is excellent, with rare episodes of mild respiratory problems only and markedly diminished pulmonary insufficiency. One child, weighing 3250 g at surgery, whose pulmonary arterial pressure did not drop below 29 mm Hg, could not be weaned off the respirator. Corrective surgery was undertaken 17 days later, but the patient died of respiratory complications. Based on clinical and Doppler sonographic findings, on control catheterization data and on haemodynamic findings in 3 surviving infants and two further patients with an uneventful course who, as yet, have not undergone surgery, we conclude that the beneficial effect of banding is the combined result of reduced pulmonary arterial pressure and decreased pulmonic regurgitation.

Atrioventricular septal defect with double-outlet right atrium

A rare type of primum atrial septal defect is described in which the atrial septum deviated to the left, resulting in a double-outlet right atrium. The obstruction at the site of the small atrial septum defect led to an elevation of the left atrial mean pressure and to pulmonary arterial hypertension. The presence of mixed blood in the right atrium caused systemic arterial desaturation. A cleft in the septal leaflet of the left atrioventricular (AV) valve caused a left ventricular-right atrial shunt, which-added to the left-to-right atrial shunt--totaled 60% of the pulmonary circulating volume. Preoperative knowledge of the anatomic features facilitated surgical repair, which consisted in resection of the abnormal septum, construction of a new septum with a Dacron patch, and closure of the septal commissure of the left-sided AV valve.

Hemodynamic changes following experimental production and correction of acute mitral regurgitation with an adjustable ring prosthesis

The hemodynamic effects of acute mitral regurgitation (MR) were investigated using a newly designed adjustable mitral ring prosthesis with remote control mechanism, implanted in mongrel dogs. The prosthesis allows to dilate the mitral annulus from outside the beating heart, and to create reversible MR of any desired degree without injuring the mitral valve apparatus. Dilatation of the mitral annulus by 25% of its circumference led to MR of angiographic grade 3+. Left ventricular systolic pressure (LVSP) dropped by 20%; dp/dtmax of the left ventricle by 16% and forward cardiac output (CO) by 31%. Left ventricular enddiastolic pressure (LVEDP) rose by 41%. The amplitude of the v-wave of the left atrium (LA) doubled, and mean LA pressure rose by 33%. If correction was carried out within one hour, then all parameters returned to normal. Maintaining the same degree of annular dilatation for two hours led to a further marked deterioration of the hemodynamics. LVSP dropped by 40%, dp/dtmax by 32% and CO by 58%. LVEDP rose by 160%. The amplitude of the v-wave of the LA increased by 300% and mean LA pressure doubled. MR, as determined by contrast 2-dimensional echocardiography (2DCE) intraoperatively, further increased in severity during the second hour, though annular size remained unchanged. In contrast to correction after one hour, correction carried out after two hours led to a slow, and, even after 12 hours, incomplete recovery. Electron microscope studies suggest papillary muscle dysfunction as a major cause of these late and partially irreversible changes.

[A rare cause of spontaneous rupture of the tendon of the extensor pollicis longus muscle]

Spontaneous rupture of extensor tendons often occurs with rheumatoid disease. Ruptures also occur after fractures of the wrist. The author reports a spontaneous rupture of the extensor pollicis longus tendon after removal of the trapezium. This occurrence has not previously been described.

Left atrial isomerism combined with right-sided heart, common atrium, incomplete atrioventricular septal defect and partial anomalous systemic and pulmonary venous drainage. Report of a case with successful surgical correction

Precise preoperative diagnostic clarification was accomplished in an infant with left atrial isomerism. The inner/outer arrangement of the pulmonary/systemic veins in relation to the posterior wall of the common atrium necessitated a specific baffle in order to prevent pulmonary or systemic venous obstruction. The development of a sick sinus syndrome six months after surgery is in keeping with the natural history of the disease.

[Modified Blalock-Taussig anastomosis. Its significance within the scope of surgical treatment of tetralogy of Fallot]

We report our results with 14 cases of tetralogy of Fallot, which were treated with a modified Blalock-Taussig shunt first, total correction having been performed in 9 of them after a mean interval of 15 months. The age of the patients ranged from 12 days to 3.3 years, with a mean of 4.7 months in 12 patients below the age of one year. In 11 cases we used a 5 mm Gore-Tex prosthesis, in 2 a 6 mm prosthesis and in one a 4 mm prosthesis. All children survived the operation. In one case shunt thrombosis occurred after a bout of pneumonia and a second shunt had to be constructed on the other side. Control angiography, performed after a mean period of 15 months in 13 patients revealed a patent shunt, though angulation of the ipsilateral pulmonary artery was noted in one case. The ratio of the diameter of the pulmonary artery to the aorta increased by 20%. The significance of these findings with regard to the question of primary or two-stage repair in infants less than one year old is discussed in view of different risk factors.

[Differential diagnosis of Madelung's deformity: Léri-Weill syndrome]

The Léri-Weill-syndrome is a very rare disease. The presence of Madelung's deformity is the important feature to distinguish this dyschondrosteosis from other system diseases of the skeleton combined with mesomelic dwarfism. Mesomelic dwarfism is mostly located in the lower extremity. If the deformity causes pain it is necessary to do a corrective osteotomy of the distal radius.

[Thermography as an additional study method in the follow-up of reconstructive operations of the hand]

The hand is very accessible to thermography. Disturbed circulation, vascular disease, tissue damage, or other causes of change in thermoproduction lead to deviation from a normal temperature chart. We found a high correlation between thermographic readings and prognosis after replantation. Thermography is, therefore, a method of examination that can be recommended.

[Apophyseal rupture of the pelvis and lower extremity caused by sports]

Apophyses are secondary ossification centers and serve as the insertion or origin of tendons. They are under a dynamic but not static load. During sexual maturity, they represent a weak point in the locomotor system. Apophyseal injuries can apparently be attributed to an incongruity between load tolerance and increased strain on the seam of the apophysis. The majority of these injuries occur during sports and involve men more frequently than women. The injury is often primarily misinterpreted as a pulled-muscle. The treatment method is dependent on the localization of the injury and the extent of the fragment dislocation.

The forearm flap as a free neurovascular flap for treatment of an extensive bone/soft-tissue defect in the calcaneal part of the foot

A discussion is presented on the case of a 28-year-old motorcyclist who had an accident and got caught in the spoked wheel of her vehicle. The result was an extensive soft-tissue injury of the metatarsus and calcaneal part of the foot, a defect fracture of the calcaneus, an osseous disinsertion of the Achilles tendon, a lateral malleolus Weber type-A fracture, and a fracture of the second metatarsal bone. The primary treatment consisted in extensive débridement of the strongly contaminated soft parts and refixation of the Achilles tendon on the calcaneus with two osteosynthesis screws. The bruised skin flaps remaining were adapted in a tension-free manner. However, this was possible only in a considerable talipes equinus position. In the further course, the patient developed an extensive skin and soft-tissue necrosis over the calcaneal part of the foot. A neurovascularly pedicled forearm flap was freely grafted in order to maintain the load capacity of the calcaneal part of the foot, to prevent osteitis of the calcaneus, to correct the talipes eqinus position, and to achieve a resensibilization in the load zone of the sole. The healing result was good, and it was possible to achieve extensive correction of the talipes equinus position as well as prevention of calcaneus osteitis; the function of the Achilles tendon was also maintained. Moreover, there was satisfactory resensibilization of the calcaneal part of the foot, so that the patient can now walk in ready-made shoes with a fully molded arch support.

Congenital aortic thrombosis with complete obliteration of the aortic arch and the great vessels

Thrombosis of the great arteries rarely occurs in the neonate. We report a case of thrombosis of the aortic arch, the brachiocephalic truncus, the left carotid and subclavian arteries, seen in a one-day-old neonate. The clinical findings were at first misdiagnosed as interrupted aortic arch syndrome, though, in retrospect echocardiography was very suggestive of the correct diagnosis. On the basis of the histological examination we assume, as the most likely cause for thrombosis, an aortitis in the prenatal period. Following thrombectomy and Gore-Tex bypass from the ascending to the descending aorta, combined with ligature of a PDA, the child developed a low output state and died on the table. The postmortem examination revealed that the latter was due to multiple infarcts of the left ventricular myocardium.

[Clinical and hemodynamic studies before and after mitral valve replacement (author's transl)]

Clinical and hemodynamic studies were carried out before and after replacement of stenotic mitral valves in 17 patients, 10 of whom received Björk-Shiley (low profile mechanical) prostheses and 7 who received (porcine heterograft) bioprostheses. Mitral valve replacement led to amelioration of symptoms, improvement of phonocardiographic findings and, partially, to a lowering of pressure in the pulmonary circulation, augmentation of cardiac output, lessening of the pulmonary arteriolar and mitral valvular resistances as well as incrementation of mitral valve orifice area. Preexistent ECG changes, radiologic heart size, right ventricular filling pressure and stroke volume remained unaltered. In consideration of variables such as prosthetic size, severity of the disease and post-operative follow-up periods, the results obtained with both types of prostheses were comparable. The prostheses, however, inherently are responsible for a moderate degree of mitral stenosis which compromises exercise capacity and generally does not lead to normalization of pressure in the pulmonary circulation. Irreversible myocardial damage appears responsible for the fact that electrocardiographic abnormalities, the heart size, the right ventricular filling pressure and stroke volume remain unaltered postoperatively. Thus, patients who have undergone mitral valve replacement continue to require limitation of physical activities, a tailored medical regimen and close cardiologic follow-up.

[Percutaneous transluminal revascularization of lower-leg arteries]

In 19 of more than 130 patients treated with percutaneous transluminal angioplasty (PTA), obstructions of the distal popliteal artery and the lower leg arteries encouraged us to extend the treatment to this vascular region. Two weeks after PTA the arteries were patent in 16 of the 19 cases (84%). These results are comparable with those of vascular surgery, but are gained with less injury to the patient and a shorter hospitalization time.

[Rupture of sinus of valsalva aneurysm. Differentiation from cardiac contusion (author's transl)]

The diagnostic aspects of rupture sinus of Valsalva aneurysm are discussed. The indication for corrective surgery can only be derived by angiocardiography. Important is the demonstration of pathophysiological hemodynamics, due to the cardiovascular anomaly. The importance of echocardiographic findings in an early phase of the clinical examination is stressed.