[Bone defects in revision total knee arthroplasty: classification and management]

The goal of bone reconstruction in revision total knee arthroplasty is to provide a stable support for the implant and to re-establish the correct joint line. Therefore, a useful, therapy-based classification of the defects is necessary. According to Stockley et al. (1992), the defects are classified into contained and uncontained defects. Uncontained defects can be reconstructed using structural allografts or metal wedges. In contained defects, cancellous allograft can be used. For aseptic loosening of total knee arthroplasty, the defect classification according to Engh and Parks (1994) can be helpful because of its recommendations for reconstruction. In case of the more common first or second graded defects, reconstruction is performed using modular revision components or allografts. For the rare third graded defects, bulk allografts or modular tumour endoprostheses are recommended. On the basis of more than 150 revision total knee arthroplasties performed in our hospital the classification of bone defects and their clinical consequences are presented in this review.

[DNA flow cytometry of bone metastases of different primary tumors]

AIM

Some human tumors of different primary localization metastasize preferably into the bone. This concerns especially kidney, breast, prostate and lung cancer. So far, the reason for this specific pattern of metastazing could not sufficiently be clarified. The aim of the study was the search for mutuality in the results of the DNA analysis of bone metastases of different primary tumors and their importance for prognosis and therapy.

METHOD

In this study, the DNA content of 40 excised bone metastases of different primary localisation has been determined by flow cytometry. By means of the DNA distribution pattern, the percentage of tumor cells in the particular cell cycle phase as well as the respective ploidy condition have been calculated.

RESULTS

Altogether, no preference of DNA diploid or DNA aneuploid stem cell lines could be found. Whether this can be applied for metastases of all primary tumors has not been clarified yet. The fact that, in 11 out of 12 tested cases of the same metastasis, DNA diploid as well as DNA aneuploid areas could be demonstrated, seems to be fundamental.

CONCLUSION

There exist a high variability of the extent of dysregulation and the intensity of the growth of bone metastasis. This does not seem to be crucial for the preferable tendency to metastazise into the bone. Due to the often insufficient tumor amount for material extraction from different areas and the large amount of DNA diploid metastases after flow cytometry analysis there should be considered the additional use of pictorial analytical methods for the DNA ploidy and proliferation assessment. A knowledge of the intensity of the course and the degree of dysregulation of tumor cell proliferation of bone metastases is beneficial in order to estimate the prognosis and to design an individual therapy regime.

Is the proliferation of human chondrocytes regulated by ionic channels?

As in cells in all living cell systems, human chondrocytes are provided with a membrane potential. The existence of ion channels in the cell membrane is an essential prerequisite for the development of membrane potential. In nonhuman chondrocytes, different ion channels have already been identified. An association between potassium channel activity and cell proliferation has been detected in different human cell systems, whereas proof of an association between ion channel activity in human chondrocytes and their proliferation has yet to be established. In this study, we investigated the concentration-dependent influence of the ion channel modulators tetraethylammonium (TEA), 4-aminopyridine (4-AP), 4',4'diisothiocyanato-stilbene-2,2'-disulfonic acid (DIDS), 4-acetamido-4'-isothiocyano-2,2'-disulfonic acid (SITS), and verapamil (vp) on the membrane potential and the proliferation of human chondrocytes, using flow cytometry. We found that the used ion channel modulators caused a change in the membrane potential of human chondrocytes. The membrane potential was decreased by 18% with 0.25 mmol/l vp (the maximal measurable effect of any of the ion channel modulators) compared with that in a control group. We measured DNA distribution in the human chondrocytes, and it was apparent that they were diploid cells with a very low proliferative tendency. These results allow us to conclude that ion channel modulators influence chondrocyte proliferation. Knowledge of the regulation of chondrocyte proliferation via ion channel modulators could serve in the research of new osteoarthritis treatment concepts.

Posteroplantar release for congenital clubfoot in children younger than 1 year

One hundred thirty-three resistant congenital clubfeet in 93 patients between 3 and 10 months of age were operated on using a standardized posteroplantar release. Clinical and radiographic assessments were done with a mean followup of 7 years 4 months (range, 3-12 years). Using the McKay score, 79.7% of the surgically treated clubfeet were classified as having a good or excellent result. Three patients had relapse of their clubfoot that required additional surgery. Seventeen feet in 15 patients had residual forefoot adduction at the time of followup. The radiographs showed that the early posteroplantar release led to sufficient hindfoot correction in all but the three patients who had relapse of the clubfoot. With this standardized surgical treatment, satisfactory results can be achieved in most patients younger than 1 year with congenital clubfoot. However, in patients with persistent talonavicular subluxation after conservative treatment, an additional talonavicular release combined with the posteroplantar release is recommended.

[Knee endoprosthesis implantation in hemophiliac arthropathy: results, problems and complications]

AIM OF STUDY

In the final stages of haemophilic arthropathy of the knee joint, the preservation of walking ability is only possible by joint replacement. Fibrotic ancylosis and severe deformities, being mostly bilaterally, make the joint reconstruction difficult and impair the results. The purpose of this study was to evaluate the results of total knee replacement (TKR) in haemophilia.

METHODS

From 1990 to 1998, 14 TKR in 7 patients with severe haemophilia were performed. The mean age at operation was 47.3 years (range, 27-62 years). The mean follow-up period was 3.7 years (range, 1-7 years). The TKR was performed bilaterally at the same time in 6 cases. In 1 case, the bilateral TKR was done one after another with 6 months interval. In 10 knee joints, an unconstrained or semi-constrained surface replacement system was used. In 4 joints, a hinged prosthesis was required.

RESULTS

The range of motion (extension-flexion) was improved from 0-23-69 degrees preoperatively to 0-4-88 degrees at follow-up. The mean HSS Score increased from 34.5 points preoperatively to 77.9 points at follow-up. Perioperatively, no haemorrhages or early infections were observed. In 1 case, 6 years postoperatively a late infection of the hinged knee prosthesis occurred. A two-stage-exchange of the prosthesis was performed. Aseptic loosenings of prosthetic components were not observed.

CONCLUSION

The TKR in haemophilia is technically demanding and requires a consequent perioperative F-VIII or F-IX substitution. A bilateral simultaneous implantation is useful. The indication for TKR has to be strict because of the higher risks and requires a close cooperation with the haemostaseologist.

Growth promoting effect of human plasma ultrafiltrate bioactive fraction (TBP) for human non-functioning pituitary adenoma cells in vitro

We described before that the chromatographically purified "human plasma ultrafiltrate bioactive fraction" (humoral factor tentatively denoted as tumor basic protein--TBP) regulates in vitro release of ACTH from pituitary adenomas stimulating the hormone release from the tumors showing low hormonal activity in vitro and inhibiting ACTH production in vitro by highly hormonally active pituitary tumors. In this study we describe growth promoting effects (determined by 3H-TdR incorporation assay) of TBP (5 microg/l, i.e. 10% w/v plasma equivalent concentration) for 10 non-functioning pituitary tumors. The effects of TBP appeared to negatively correlate with the in vitro growth abilities of the tumors that were otherwise dependent on the duration of the clinical symptoms of the tumor presence. Hence, similar to its effects on hormonal activity of the pituitary tumors, TBP stimulated the growth of the tumors which did not express high spontaneous 3H-TdR intensity, but did not stimulate the cells with high capacity of spontaneous 3H-TdR incorporation. Moreover, all the tumors that were stimulated by TBP were nononcocytic adenomas while oncocytoma cells were not stimulated at all. Thus, TBP shows activity of humoral (plasma) factor involved in the growth regulation of pituitary adenomas that might be used to define the growth abilities of these tumors, especially in case of null cell adenomas and oncocytomas as were the tumors used in this study.

Arthroscopy after dysfunctional total knee arthroplasty: two cases with peg fracture of the polyethylene insert

Arthroscopy may be indicated in patients with painful dysfunction of the knee joint following total joint replacement. Arthrofibrosis, impacted soft tissue, patellar malalignment, synovialitis, and intra-articular foreign bodies can be treated with the promise of a good outcome. Two cases of peg fracture of the polyethylene insert of a semiconstrained knee prosthesis are presented. In relation to fracture position, instability and locking-up of the joint were clinically manifest. When arthroscopy is used judiciously, its merits are found in ensuring the proper diagnosis and in the reliable planning of treatment. When the patient reports locking-up of the joint, the rare complication of a polyethylene peg fracture must be considered.

[The effect of arthroscopic joint debridement in advanced arthrosis of the knee joint]

A retrospective study was performed examining 84 patients who had undergone arthroscopic debridement for high-grade osteoarthritis of the knee joint. After an average follow-up period of 52 (35-72) months only 14 (16.7%) patients indicated an improvement of the preoperative situation. 36 (42.8%) patients had severe joint pain after one year postoperatively. 17 (24.3%) patients were evaluated with 85-100 points and 53 (75.7%) patients with less than 85 points in a modified Lysholm-score. There were better results in younger patients (< 50 years). Compared with the literature, aggressive subchondral abrasion does not show any benefits. Patients' preoperative expectations have to be clearly objectified. With this prerequisite the surgical procedure as an operation with low complication risk can also be justified as a temporary alternative to total knee arthroplasty in patients suffering from a high-grade degeneration of the knee joint.

[ROBODOC--a path into the future of hip endoprosthetics or an investment error?]

GOAL

The Orthopaedic Department of Martin-Luther-University has been using computer-guided, robot-assisted surgery in cementless total hip arthroplasty since June 1997. The goal of the present paper is to critically evaluate the advantages and disadvantages of the ROBODOC system when using two different femoral components and the employment of the system in orthopaedics in general.

METHOD

Between June 1997 and August 1999 87 procedures have been performed using the ROBODOC system. 48 ABG stems and 39 OSTEOLOC stems manufactured by HOWMEDICA were used. The results are based on a prospective study.

RESULTS

The main advantage of the system is the excellent three-dimensional preoperative planning and the precise execution of the preoperative plan during surgery. Problematic situations of the proximal femur can be evaluated and the optimal position of the femoral component can be guaranteed. Investigations on cadaver femurs showed significant differences in the bone-implant contact. The first results let us expect some advantage in congenital and acquired femoral deformities.

CONCLUSION

The ROBODOC system has to be critically considered as an alternative to hand implantation. In our opinion, it should be used only under certain circumstances considering the current technical progress. Only in these cases the potential of the system can be used beneficially.

[Etiology of early loosening after aseptic cup replacement using allogenic bone blocks and cement-free press-fit cups]

PURPOSE

There are two problems using structural allografts in revision total hip surgery. The long-term stability of bulk allografts and the intraoperative primary stability of the graft and implant limit the success of this revision philosophy. The purpose of this study was to analyse the reasons of early loosening of cementless cups after reconstruction with bulk allografts.

METHOD

In a retrospective study 78 revisions were analysed radiologically. The preoperative stage of bone destruction, the size of allografts, the implant-allograft coverage, and the position of implants were analysed in X-ray series.

RESULT

There were 12 (15.3%) cases with aseptic and 5 (6%) cases with septic cup loosening, after revision surgery, with an average follow-up of 37 (25-84) months. All of these failures were registered in the first 12 months postoperatively. Large bone defects and an implant-allograft coverage of more than 50% are significant (p < 0.001) risk factors of early aseptic loosening.

CONCLUSIONS

It is important to give careful attentions to primary stability, especially in revision total hip arthroplasty using structural allografts and cementless cups. For primary stability as well as secondary stability a stable fixation with as large as possible areas of contact between implant and living bone is necessary. The limit of the method (allograft and cementless cup) is to be seen in stage 2B according Paprosky (1990). In larger defects alternative reconstruction methods have to be used.

Substitution of tibial bony defects with allogeneic and autogeneic cancellous bone: encouraging preliminary results in 18 knee replacements

Eighteen knee replacements in 15 patients with severe gonarthritis or loosening of total knee arthroplasty (TKA) requiring bone grafting for bony deficiencies were studied before and after operation. The average follow-up was 2.4 years. Fifteen knees showed satisfactory clinical and radiographic results of the integration of the bone grafts. The Hospital for Special Surgery knee score improved from an average of 39 points preoperatively to 83 points at the most recent follow-up examination. Two of 3 knees with loosening of the tibial component required revision. These results are encouraging. Success depends as much on rigid fixation of the grafted bone and protected weight-bearing as on rigid, micromotion-preventing fixation of the tibial component.

[Cerebellar hemorrhage as an early complication of spinal operations. 2. Case reports and review of the literature]

GOAL

The present paper investigates the etiology and pathogenesis of cerebellar hemorrhage after spine surgery.

METHOD

This paper reports two patients in those this complication was seen. In respect to the current literature we discuss the etiology and pathogenesis of cerebellar hemorrhage due to spine surgery.

RESULTS

Cerebellar hemorrhages represent a life-threatening situation. There are no reports in the literature about cerebellar hemorrhage as an early complication of intraoperative dura injuries in spine surgery. It seems that a bigger cerebrospinal fluid loss is responsible for the developing of cerebellar hemorrhages. The loss creates a pressure gradient from infratentoriell to site of lesion and also leads to mechanical stress on cerebellar blood vessels such as traction, tearing and kinking.

CONCLUSIONS

Every condition after spine surgery with dura injuries and neurological deficits should be carefully evaluated and intracranial hypotension as well as hemorrhage should be ruled out.

[Results of shoulder hemiarthroplasty in patients with acute and old fractures of the proximal humerus]

STUDY-DESIGN

We report on a prospective study of 22 patients after shoulder hemiarthroplasty in acute and old proximal humerus fractures.

METHOD

Nine patients with an acute and 13 with an old humerus fracture, in whom a hemiarthroplasty was performed have been evaluated clinically using the Constant score as well as radiologically on average 22 months postoperatively.

RESULTS

The mean Constant score improved on 28 points (27 to 55). The improvement was especially distinct in the group with acute fractures. Sixteen of the twenty examined patients were painfree. Two patients reported sleeping disturbances due to pain. The ROM was improved, especially in forward elevation and abduction. In two patients with an old fracture the results were less satisfying. Major complications could not be observed. In five cases X-ray revealed an atrophy of the fixated fragments. Dislocations did not occur. Radiological changes of the glenoid, already seen preoperatively became more obvious. Some humeral components, inserted without cement, showed "densification lines". There were no clinical signs of loosening.

CONCLUSION

By performing hemiarthroplasty pain relief can be achieved, especially in old fractures. The postoperatively achieved joint function mainly depends on the type of fracture as well as ist age. In cases with a destroyed glenoid we now prefer to perform a total arthroplasty. In our opinion, general cement use for shaft fixation is not necessary.

Insulin-like growth factor 1 and 2 serum concentrations in dialysis patients with secondary hyperparathyroidism and adynamic bone disease

BACKGROUND

Insulin-like growth factor-1 and -2 exert well characterized effects on bone metabolism via paracrine and endocrine pathways. However, the role of circulating levels of IGFs and their binding proteins (IGFBP) in renal bone disease is still controversial.

PATIENTS AND METHODS

To investigate whether circulating IGFs play a role in the pathogenesis of different forms of renal bone disease, we performed a cross sectional study in 38 stable dialysis patients (32 hemodialysis, 6 peritoneal dialysis). Patients were selected for the type of bone disease according to biochemical bone markers and bone histology. 25 Patients had adynamic bone disease (ABD; defined by plasma iPTH < 1,5 fold the upper limit of normal). Thirteen patients had secondary hyperparathyroidism (sHPT; defined by plasma iPTH > 10 fold the upper limit of normal). Serological diagnosis was confirmed in a subgroup of patients by bone histology (12 patients with type IIa according to Delling, ABD; 9 patients with type IIIb according to Delling, sHPT). Patients with signs or symptoms of aluminum toxicity were excluded from the study.

RESULTS

Serum IGF-1 and -2 concentrations were comparable in both groups and were within the reported normal range for an age matched healthy control population. They did not correlate with biochemical markers (iPTH, bAP, osteocalcin) or histological manifestations of renal bone disease. Furthermore, semiquantitative analysis of IGFBP-2 and -3 carried out in patients with bone biopsies did not correlate with biochemical markers or histological indices of renal bone disease.

CONCLUSION

In conclusion, in contrast to previous reports, the present data do not confirm a correlation between serological or histological markers of renal osteodystrophy and circulating IGF-1 or -2 or IGFBP-2 and -3. This does not exclude that potential alterations of the local IGF system may play a role in the pathogenesis of uremic bone disease.

Biomechanical and densitometric bone properties after callus distraction in sheep

Assessment of biomechanical stability of diaphyseal bone lengthened by callus distraction is an unsolved problem. A middiaphyseal corticotomy was performed in the left tibia of 24 sheep. After 7 days, callus distraction was begun at a rate of 0.5 mm every 12 hours for 30 days using a standard unilateral fixator system. Animals were euthanized 4, 8, or 12 weeks after the end of distraction. The lengthened tibia and the contralateral control tibia from each animal were evaluated by radiographic, densitometric (dual energy xray absorptiometry, quantitative computed tomography), and biomechanical (axial compression testing, torsion testing to failure) methods. The bone mineral density and maximum torque for the lengthened tibia were significantly greater in the 8-week group than in the 4-week group. However, the values in the 12-week group were significantly smaller than in the 8-week group. In the lengthened tibias, there was a correlation between the maximum torque and the bone mineral density, and between the maximum torque and the bone density. Bone density measurements are useful prognosticators for the safe removal of external fixators after leg lengthening procedures. By using these methods, clinical fractures after leg lengthening could be avoided in the future.

[Possibilities of follow-up imaging after implantation of a carbon fiber-reinforced hip prosthesis]

INTRODUCTION

There are many problems in the radiological diagnosis of aseptic loosening in total hip arthroplasty. Computed tomography (CT) and magnetic resonance tomography (MRT) are not usable for metallic implants (stainless steel, cobalt alloy, titanium alloy).

MATERIAL AND METHODS

From April 1993 to December 1993 15 CFRP non-cemented hip prostheses have been implanted. In a prospective clinical study plane radiographs, CT and MRT have been analysed.

RESULTS

Three stems were revised (1 femoral fracture, 1 severe thigh pain, 1 aseptic loosening). CFRP are not visible in plane radiographs. There was a complete (two-third of the cases) or nearly complete (one-third of the cases) small sclerotic interface between the prosthesis and the bone, these were apparent in CT and MRT in stable implant cases and did not have any clinical correlations.

DISCUSSION

The small sclerotic interface is quite different in comparison to so called "Reactive Lines". In one case of aseptic loosening there was an interposition of soft tissue between prosthesis and bone in MRT and CT. CFRP inaugurates new diagnostic possibilities in aseptic loosening of hip prosthesis and in tumour surgery too.

Regulation of intestinal vitamin D receptor expression in experimental uraemia: effects of parathyroidectomy and administration of PTH

In this study, the effects of PTH on binding of [3H]-1,25-dihydroxyvitamin D3 [1,25(OH)2D3] and on vitamin D receptor (VDR) mRNA concentration were assessed in intestinal mucosa of subtotally nephrectomized rats (Nx) and in intestinal mucosa of sham-operated rats with normal kidney function (Intact). Intestinal 1,25(OH)2D3 binding capacity of Intact remained unchanged (i) after parathyroidectomy (PTx), (ii) after administration of PTH for up to 6 days, and (iii) after PTx and subsequent administration of PTH (n = 4 experiments). In contrast, PTx of subtotally nephrectomized animals (Nx-PTx) decreased 1,25(OH)2D3 binding capacity from 757 +/- 95 fmol/mg protein in Nx to 417 +/- 42 in Nx-PTx (P < 0.01, n = 5). PTH administration had no effect on intestinal 1,25(OH)2D3 binding capacity in Nx. However, PTH administration to Nx-PTx resulted in re-elevation of 1,25(OH)2D3 binding capacity to a level (790 +/- 113 fmol/mg protein) which was comparable to Nx. Kd-values remained unaltered under all experimental conditions. The intestinal VDR mRNA concentration (normalized to beta-actin mRNA) was decreased, on average, by 23% in Nx-PTx (P < 0.05 versus Nx). In further experiments, 1,25(OH)2D3 was administered to Nx-PTx. This resulted in upregulation of 1,25(OH)2D3 binding capacity as compared to vehicle-treated Nx-PTx (562 +/- 90 fmol/mg protein versus 249 +/- 32, P < 0.01). The latter results could indicate that PTH-mediated stimulation of residual renal 1,25(OH)2D3 production was involved in PTH-mediated up-regulation of intestinal 1,25(OH)2D3 binding capacity in Nx-PTx. To rule out this possibility, PTH was administered to totally nephrectomized and parathyroidectomized rats (TNx-PTx). Since PTH caused an approximately 80% increase (P < 0.05) in intestinal 1,25(OH)2D3 binding capacity under those experimental conditions a mediator role of 1,25(OH)2D3 could be excluded. Functional significance of decreased intestinal 1,25(OH)2D3 binding capacity in Nx-PTx as compared to Nx was demonstrated by significantly lower 1,25(OH)2D3-mediated stimulation of intestinal 25(OH)D3-24-hydroxylase activity in Nx-PTx (209 +/- 68 pmol/mg protein) than in Nx (385 +/- 81, P < 0.01). The modulation of intestinal 1,25(OH)2D3 binding capacity was not correlated with changes in calcium, phosphate or 1,25(OH)2D3 serum concentrations under our experimental conditions. Taken together, intact parathyroid gland function was required to maintain adequate intestinal VDR expression in experimental uraemia (but not in normal animals). The mechanism of the modulation of intestinal VDR by PTH remains to be elucidated although an indirect effect of PTH on VDR expression in intestinal mucosa seems most likely.

First Report of Banana Streak Virus Infecting Sugarcane and Arrowroot in Colombia

We have recently reported on the presence of banana streak virus (BSV) affecting plantains (Musa spp.) in Colombia (2). BSV is serologically related to sugarcane bacilliform virus and has been found to be transmitted by the pink mealybug (Saccharicoccus sacchari) from sugarcane to banana (1). In the vicinity of affected plantain crops in the localities of Andes (Antioquia) and Montenegro (Quindio), we observed sugarcane (Saccharum officinarum L.) plants with chlorotic streaks on their leaves, as well as arrowroot (Canna edulis Ker-Gawl.) plants with mild mosaic symptoms. The foliar tissue of symptomatic plants of these two species was tested for BSV and cucumber mosaic virus (CMV) by double antibody sandwich-enzyme-linked immunosorbent assay with commercial polyclonal antisera (Agdia Inc., Elkhart, IN). BSV was detected in samples of both plant species, whereas CMV was not detected in either one. Immunosorbent electron microscopy analysis of BSV-infected, symptomatic, foliar tissue of sugarcane showed the presence of viral-like bacilliform particles measuring approximately 150 × 30 nm, typical of BSV. This is the first report of BSV infecting Saccharum officinarum in Colombia and the first report of Canna edulis as a host for this virus. References: (1) B. E. L. Lockhart and L. J. C. Autrey. Plant Dis. 72:230, 1988. (2) H. Reichel et al. Plant Dis. 80:463, 1996.

[Comparison of roentgenological, macroscopic and histological degree of degeneration in varus gonarthrosis]

In 20 cases of varus gonarthrosis the degree of severity of osteoarthrosis was assessed preoperatively, intraoperatively and postoperatively for the medial and lateral compartments, respectively. The preoperative assessment was carried out on the basis of x-ray taken in an anterior-posterior and lateral view, whereas the intraoperative assessment was based on the recognizable macroscopic alteration of the femur and tibia. Following implantation of a total knee prosthesis, the resected osteocartilogical samples were assessed from a histological point of view. In the case of varus gonarthrosis there is a distinct difference in the degree of degeneration in the medial and lateral compartments. This difference becomes less noticeable if the assessment is carried out intraoperatively. The histological analysis shows that there are certainly differences between the compartments from a quantitative point of view but a late stage of osteoarthrosis was discernible both medially and laterally. From a histological point of view the radiological concept of the so-called "unicompartmental varus gonarthrosis" cannot be supported. In both compartments the osteoarthrotic process is more uniform than is to be expected.

[Septic myocardial aneurysm in mitral valve endocarditis. Clinical and pathological-anatomical findings]

HISTORY AND CLINICAL FINDINGS

A 68-year-old woman was hospitalized because of fever and tiredness for 3 months. Her general condition was clearly impaired. She had a mild fever of 38.5 degrees C and on auscultation a 3/6 systolic murmur, maximal parasternally in the 3rd intercostal space, transmitted to the apex. There were distant râles over both lungs, the neck veins were distended and there was ankle oedema.

INVESTIGATIONS

C-reactive protein was raised to 17.3 mg/dl (normal up to 0.9 mg/dl), WBC count 19,300/microliter. beta-haemolysing streptococcus (S. agalactiae) was grown in the blood culture. The ECG showed sinus tachycardia (rate of 98/min) and transthoracic echocardiography demonstrated a small pericardial, enlarged ventricles, marked mitral regurgitation and a large vegetation on the posterior mitral leaflet, as well as a 3 x 4 cm mass in the posterior wall of the ventricle, originating from the posterior mitral valve ring and communicating with the vegetation on the mitral valve. The posterior mitral leaflet was perforated.

TREATMENT AND COURSE

As endocarditis of the mitral valve with a complicated course was suspected-abscess of the posterior mitral valve ring and septic myocardial aneurysm with associated pericarditis and haemodynamically insignificant effusion-she was transferred to the intensive care unit where she died suddenly of circulatory arrest only 30 min after transfer. Autopsy confirmed the echocardiographic findings.

CONCLUSION

Paravalvular abscess in the course of mitral valve endocarditis is rare, but should be looked for at transthoracic echocardiography so that any necessary surgical intervention can be undertaken early.