Allogenic grafting of vascularized bone segments under immunosuppression. Clinical results in the transplantation of femoral diaphyses

Trauma surgery lack, substitute, for the reconstruction of large defects of the long bones. Encouraged by the promising results of bone allotransplantation in animal models, we successfully performed vascularized bone transplantation in humans. Vascularized femoral diaphyses were allogenically transplanted into three patients suffering from chondrosarcoma or post-traumatic osteomyelitis with postoperative immunosuppression. The bone segments were harvested from multi-organ donors and perfused with UW solution. After back-table preparation, the grafts were transplanted into the defect zone. Interlocking devices were used in these operations. Vascular anastomoses were performed in end-to-side technique. The early clinical course of the patients was not free of anatomical, technical, or immunological complications. However, all patients are currently free of malignancy and infection. They are also free of pain and full weight bearing. We conclude that allogenic grafting of vascularized bone segments has the potential to become an alternative for the replacement of large bone defects.

[As lumbago treated, delayed diagnosis of large intestine perforation with extremely severe peritonitis--case report with focus on the value of diagnostic laparoscopy]

We report on a colon perforation with peritonitis which remained clinically undetected until the 4th day post trauma although the patient suffered from lumbalgia-like symptoms. He then developed an acute abdomen with sudden onset, being caused by a sigmoidal rupture and a consecutive diffuse peritonitis. A colon resection was performed according to the Hartmann procedure. Almost 36 revisions were necessary due to necrosis and perforation. Having treated the peritonitis successfully it was possible to close the abdomen and to remove the stomata. The case is discussed in relation to standard diagnostic procedures while a special interest is focused on the usage of sonography, explorative laparoscopy and laparotomy. We finally introduce the algorithm being applied to similar cases at our trauma center.

[Early infection after surgical fracture treatment: therapy with reference to socioeconomic aspects]

Early postoperative infection following open reduction and internal fracture fixation is the most serious complication in orthopedic surgery. The transformation of an acute osteitis into a chronic form marks the central problem. Every single case of chronic osteitis represents an economic disaster.

The arterial blood supply of the human patella. Its clinical importance for the operating technique in vascularized knee joint transplantations

The architecture of the arteries supplying the patellar rete was examined in 14 anatomic specimens in order to develop an optimized operating technique for knee joint transplantation. The specimens were fixed in Jores Solution and exarticulated from the hip joint. The lower limbs were injected with Berliner-Blau-Gelatin, and the arteries were dissected macroscopically. Five to six main arteries entered the patellar rete at 1, 3, 5, 7 and 11 o'clock forming an arterial circle. These arteries were the same main arteries which supply the distal end of the femur and the proximal part of the tibia. From an anatomic perspective, they provide the complete arterial blood supply to a whole knee joint being transplanted including the patella. Based on these anatomic results, we transplanted two allogenic vascularized human knee joints preserving the patella, the capsule, and the patellar ligament. Up to six months after surgery we demonstrated the perfusion and viability of all three transplanted bones, particularly the patella, by 99mTc DPD scintigraphy. We compared these findings with knee joint arthroscopy and with histologic results from biopsies taken from the patella. The postoperative examinations clearly indicated the viability of the transplanted patella employing this new operating technique. The results of the entire study demonstrate that it is technically feasible to transplant a whole knee joint which remains clinically viable.

Neutrophil activation after skeletal muscle ischemia in humans

The aim of the study was to investigate the time course of neutrophil activation after skeletal muscle ischemia in humans and to assess the effect of xanthine oxidase inhibitor allopurinol or cyclooxygenase inhibitor indomethacin. In patients undergoing tourniquet ischemia of the upper limb, polymorphonuclear neutrophils (PMN) were simultaneously isolated from antecubital vein blood of both the contralateral control arm and the tourniquet arm. PMN-superoxide production (PMN-SOP) was determined by a cytochrome C reduction assay, PMN-myeloperoxidase activity (PMN-MPO) by guaiacol oxidation and serum PMN-elastase concentration by an enzyme immunoassay. At 60 min after release of the tourniquet, significant increases of PMN-SOP, PMN-MPO, and serum elastase concentrations were observed in tourniquet arms as compared with control arms (p < .05). Allopurinol (300 mg orally, 12 and 2 h before ischemia) significantly inhibited the increase of PMN-SOP, PMN-MPO, and serum elastase (p < .05). Indomethacin (50 mg orally, 2 h before ischemia) prevented increased PMN-MPO and serum elastase, but prevented increased PMN-SOP only when neutrophils were incubated in the presence of their autologous plasma. These findings suggest that ischemia/reperfusion of human skeletal muscle involves both xanthine oxidase-dependent oxygen free radicals and cyclooxygenase metabolites. These pathways could activate circulating neutrophils which potentially inflict local and remote endothelial injury.

[Minimally invasive ventral spondylodesis in injuries to the thoracic and lumbar spine]

Thirty-eight patients with 40 fractures of the thoracic spine and the thoracolumbar junction were treated by a minimally invasive procedure, which includes partial corporectomy, the interposition of a tricortical bone graft and anterior stabilization by plate spondylodesis under thoracoscopic control. For 36 patients the operation was successfully performed in a complete thoracoscopic way; in 2 patients conversion to an open technique was necessary. Two postoperative complications such as a reversible lesion of the thoracodorsalis nerve and a transient irritation of nerve root L1 on the approach side were encountered. Postoperative control by X-ray and CT scan showed correct positioning of the bone graft, as well as the fixation device in all patients. Our experience with this minimally invasive stabilizing procedure for injuries of the thoracic spine and the thoracolumbar junction demonstrated the feasibility of the method. Compared to the open method the benefit of minimally invasive surgery included postoperative pain reduction, shorter hospitalization, early recovery of function and reduced morbidity of the operative approach.

[The osteosynthesis implant and early postoperative infection: healing with or without removal of the material?]

This prospective study served as a quality control of a revision concept for case of post-traumatic infection following open reduction and internal fixation in fracture treatment. It is based on clinical and microbiological criteria and has two aims: (1) eradication of the infection and avoidance of development of chronic osteitis; (2) maintenance of internal fixation, if possible. Thirty-four patients were recruited in this study. Surgical revisions were performed according to a consistent concept (debridement, irrigation, local chemotherapy, drainage) in defined time intervals (2 days). The operation site had to be bacteriologically clean after four revisions. Otherwise, the implant had to be removed. Both aims were reached in 11 cases: management of infection with maintenance of internal fixation. In 23 cases the implant material had to be removed. Nevertheless the infection was eliminated in all these patients without exception. The following risk factors for mandatory implant removal were evaluated: diabetes, arteriosclerosis, alcoholism, nicotine. This revision concept helps in the management of acute postoperative osteitis following ORIF in fracture treatment and in avoiding the development of chronic osteitis.

Allogeneic vascularized grafting of a human knee joint with postoperative immunosuppression

In this paper we report the first successful allogeneic vascularized transplantation of a fresh and perfused human knee joint. A 17-year-old male had lost his knee in a motorvehicle accident. The graft was harvested from a multiorgan donor, perfused with 41 UW solution and transplanted within 21 h. Osteosyntheses were performed employing intramedullary nails. Immunosuppression was based mainly on two drugs: cyclosporin A and azathioprine. Five months after the operation the patient is fully mobilized, and the graft perfusion still intact. Osteotomies of the femur and tibia demonstrate callus formation and osseous consolidation.

Intestinal ischemia: reperfusion-mediated increase in hydroxyl free radical formation as reported by salicylate hydroxylation

Oxygen free radicals may play a pivotal role in the development of the shock-induced inflammatory response syndrome. Hydroxyl free radicals (.OH) react with salicylate (SA) to form 2,5- and 2,3-dihydroxybenzoic acid (DHBA) products. We utilized salicylate hydroxylation to investigate .OH formation during intestinal ischemia/reperfusion injury in male Sprague-Dawley rats. After administering salicylate, the superior mesenteric artery was occluded for 45 min and then allowed to reperfuse for 90 min after declamping. No significant changes in plasma 2,3- and 2,5-DHBA/SA ratios were observed in sham-operated or in animals given intestinal ischemia without reperfusion. A significant increase (p < .05) in arterial, venous, and portal venous 2,5-DHBA/SA ratios occurred 5 min after reperfusion. This increase was prevented by allopurinol as well as by dimethylthiourea (.OH scavenger) pretreatment. 2,3-DHBA was significantly increased (p < .05) in venous and portal venous blood after 30 min of reperfusion, but was not detectable in plasma of allopurinol- and dimethylthiourea-treated rats. These results indicate that hydroxyl free radical formation as reported by SA hydroxylation appears to be important in intestinal ischemia/reperfusion-related tissue injury.

Dose-related pattern of sinusoidal leukocyte adhesion in sublobular regions of the liver after systemic endotoxin challenge in the rat

The unique arrangement of large numbers of fixed tissue macrophages, endothelial, and parenchymal cells along hepatic sinusoids as well as their key role in the acute phase response makes the liver a primary target organ in endotoxemia. Pathogenesis of hepatic failure in endotoxemia is incompletely understood, but microcirculatory failure as well as leukocyte-endothelial interaction in response to inflammatory mediators may relate to it. Using intravital fluorescence microscopy, sinusoidal widths, leukocyte flow velocity, and sublobular leukocyte (white blood cell (WBC)) adhesion characteristics 1 h after randomized intravenous application of 0, 0.1, 1, or 5 mg/kg b.w. Escherichia coli endotoxin O 111 B4 (ETX) were evaluated in female Sprague-Dawley rats (n = 6-8/group). Whereas the bolus injection of ETX caused only minor concurrent macrohemodynamic effects, a significant increase of permanent WBC adhesion especially in periportal areas (0 mg, 2.1 +/- 0.7%; 0.1 mg, 16.2 +/- 3.6%**; 1 mg, 15.5 +/- 1.0%**; 5 mg, 13.2 +/- 2.3%* (**p < .01, *p < .05, compared to vehicle)) was found in all groups 60 min after ETX challenge. In contrast, an increase of WBC margination in midzonal and pericentral regions was only seen with the higher doses of 1 or 5 mg/kg ETX, respectively. The sublobular pattern of WBC margination is consistent with the concept of regulation of WBC adhesion by inflammatory mediators released by lipopolysaccharide-stimulated Kupffer cells in vivo. We propose that overwhelming the detoxifying capacity of predominantly periportally located Kupffer cells with large amounts of ETX may lead to activation of pericentral-located resting macrophages paralleled by a rise of adhering leukocytes.

Macrophage activation and leukocyte adhesion after liver transplantation

Reperfusion injury involving oxygen radicals, leukocyte adhesion, and Kupffer cell activation has been suggested to contribute to the failure of transplanted livers. The aim of this study was to evaluate Kupffer cell activity, leukocyte adhesion, and the effect of the calcium channel blocker nisoldipine after rat liver transplantation by means of in vivo fluorescence microscopy to further investigate the mechanism of graft failure. Inclusion of 1.4 microM nisoldipine to the University of Wisconsin cold storage solution (UW) did not improve sinusoidal perfusion and vasoconstriction after transplantation compared with UW alone (82.7 +/- 1.0% vs. 79.2 +/- 1.7% perfused sinusoids; 7.3 +/- 0.1 vs. 8.0 +/- 0.2 microns diam of sinusoids; means +/- SE). Permanent as well as temporary adhesion of leukocytes rose from 9.4 +/- 0.8 and 10.2 +/- 0.5% in sham-operated controls to 19.1 +/- 2.2 and 19.2 +/- 0.5% after liver transplantation, respectively. Inclusion of the calcium channel blocker reduced permanent (9.1 +/- 0.8%; P < 0.05) and temporary adherent leukocytes (11.3 +/- 1.0%; P < 0.05). Phagocytosis of latex beads by Kupffer cells or other phagocytic cells as a function of activity rose after transplantation (e.g., periportal area: 509 +/- 44/mm2) compared with controls (316 +/- 22/mm2). This was significantly reduced by inclusion of nisoldipine to UW (322 +/- 32/mm2). The results of this study demonstrate activation of Kupffer cells and increase of leukocyte adhesion to the sinusoidal endothelial wall during reperfusion of transplanted livers. A calcium-dependent release of mediators by Kupffer cells that promote leukocyte adhesion is suggested as an underlying mechanism.

Value of superoxide dismutase for prevention of multiple organ failure after multiple trauma

In a prospective, randomized trial, recombinant human superoxide dismutase (rhSOD, 3000 mg/day, Grünenthal, Aachen, Germany) or placebo was given intravenously during 5 days after multiple injuries (Injury Severity Score [ISS] > or = 27; 24 patients). Manifestation of multiple organ failure (MOF) and posttraumatic inflammatory response were evaluated over 14 days. No side effects were noted by continuous infusion of rhSOD, which allowed high SOD plasma levels (24.77 +/- 9.43 mg/L) compared with controls (0.03 +/- 0.02 mg/L). Multiple organ failure was attenuated by rhSOD treatment in respect to cardiovascular and pulmonary functions. Additionally, intensive care therapy was shortened from 30 days (Q25: 15; Q75: 37) to 21 days (Q25: 12; Q75: 41). A secondary increase of inflammatory mediators (e.g., C-reactive protein, polymorphonuclear [PMN]-elastase, phospholipase A2), as observed at the end of the first week in the placebo group, was reduced by rhSOD therapy. The results reveal an attenuation of organ failure after trauma, most likely by decreasing the release of inflammatory mediators and reduction of leukocyte-mediated organ injury. These preliminary results, while promising, need to be confirmed in a larger number of patients.

Comparative effects of crystalloid and small volume hypertonic hyperoncotic fluid resuscitation on hepatic microcirculation after hemorrhagic shock

Hepatic microcirculation, leukocyte-endothelial interaction, and sinusoidal widths were studied by means of intravital microscopy in a non-heparinized fixed pressure hemorrhagic shock model in the rat. Asanguineous resuscitation was performed either with "adequate" amounts of lactated Ringer's solution (threefold shed volume/30 min) or 4 ml/kg/3 min 7.2% saline/10% Dextran 60 (HSDex) or 4 ml/kg/3 min 7.2% saline/10% hydroxyethylstarch 200/0.62 (HSHes). Hemorrhagic shock and resuscitation was paralleled by significant (P < 0.01) lumenal narrowing of sinusoids that remained largely uninfluenced by the type of fluid used for resuscitation (HSDex: 9.28 +/- 0.56; HSHes: 8.93 +/- 0.29, LR: 8.87 +/- 0.6 microns compared to 12.17 +/- 0.24 microns in controls). Whereas HSHes and LR-therapy resulted in comparably increased leukocyte adhesion to the sinusoidal wall, the dextran-containing solution led to a significant attenuation of leukocyte-endothelial interaction, suggesting involvement of dextran-binding adhesion molecules, e.g., selectins.

Leukocyte-endothelial cell interactions in the liver after hemorrhagic shock in the rat

Leukocyte-endothelial cell interactions in rat livers were investigated using intravital fluorescence microscopy following hemorrhagic shock (MAP at 40 mm Hg for 60 min) and resuscitation. Thirty minutes after resuscitation, when MAP was higher than 100 mm Hg, sinusoidal perfusion was only slightly reduced (>90% of controls). Firm adhesion of leukocytes increased to 370 +/- 54 leukocytes/mm2 after shock and resuscitation compared to control animals (48 +/- 8/mm2; mean +/- SEM; P < .01). Leukocyte-endothelium adhesion was highest in the portal areas and lowest in midzonal and pericentral regions (relationship:2.0: 1.1:1.0). Pretreatment with dexamethasone (5 mg/kg bw) resulted in a dramatic rise of adherent leukocytes following hemorrhagic shock (920 +/- 62/mm2; P < .001). Pretreatment with ibuprofen (15 mg/kg bw) resulted in a similar increase of adherent leukocytes after hemorrhagic shock (750 +/- 60/mm2; P < .001), while pretreatment with MK 886(10 mg/kg), inhibitor of lipoxygenase pathway, reduced leukocyte adhesion slightly (270 +/- 38/mm2). The results reveal that leukotrienes, e.g., released by activated macrophages, are involved in the regulation of leukocyte adhesion in liver sinusoids following hemorrhagic shock and resuscitation. The negative effect of dexamethasone and ibuprofen on hepatic leukocyte adhesion, however, has to be considered for therapeutic use.

[Osteosynthesis using a buttress plate--a new principle for stabilizing scaphoid pseudarthroses]

Deformity with palmar bone resorption can be observed in 20-50% of scaphoid pseudarthroses. A palmar wedge-shaped defect develops after repositioning and debridement of the pseudarthrosis. In the present paper 16 cases in which operations with cancellous bone grafting and palmar buttress plate osteosynthesis in addition were performed are presented. In all but 1, the pseudarthrosis united. All patients were pain-free at follow-up examination a minimum of 9 months (mean 28 months) only slightly reduced. Grip strength and mobility were after operation. The persisting pseudarthrosis necessitated wrist arthrodesis because of radiocarpal arthrosis. Metal slackening with erosion and rupture of the flexor pollicis longus tendon occurred in 1 patient. Palmar buttress plating is a biomechanically consistent form of osteosynthesis. It neutralizes all relevant forces. This means that cancellous bone grafts are sufficient, whereas lag screw or tension band osteosyntheses need cortico-cancellous grafts to resist compression forces. Stability and better chances of healing of pure cancellous bone grafts are the main advantages of palmar buttress plating in scaphoid pseudarthroses.

[A simple method for repositioning metatarsal fractures]

Because of small direct contact to the fracture fragments reduction of metatarsal fractures can be achieved only indirectly by applying traction to the toes. In this article a method for simple direct manipulation of the distal main fragment of metatarsal fractures is described: A K-wire is drilled in dorsi plantar direction across the head of the fractured metatarsal and mounted on a traction bow. In this manner the distal fracture fragment can be moved in all directions and placed exactly onto the proximal fragment. All 8 patients with multiple metatarsal fractures could be treated by closed reduction and percutaneous pinning. The described method allows simple and precise reduction of metatarsal fractures, reduced x-ray exposure of the surgeon's hand by short operation times, and manipulation for fracture reduction outside the x-ray beam.

[Thumb reconstruction with cryopreserved autogenous thumb skeleton and microneurovascular flap]

This paper describes a procedure for thumb reconstruction using autogenous cryo-conserved bone from the thumb itself. In a case of severe explosion injury, the thumb and index finger were amputated at the carpometacarpal joint level and the remaining fingers at the distal interphalangeal joint level. Severe soft tissue damage and lesion of both the superficial and deep palmar arterial arches rendered customary surgical procedures for thumb reconstruction impossible. The cryo-conserved bone was replanted following soft tissue healing and then covered with a free radial forearm flap. This procedure resulted in a stable and painfree thumb and provided satisfactory grip.

Improvement of liver preservation by the calcium channel blocker nisoldipine. An experimental study applying intravital microscopy to transplanted rat livers

It has been shown recently that inclusion of the calcium channel blocker nisoldipine to University of Wisconsin (UW) solution significantly improves survival after rat liver transplantation. To further elucidate the mechanisms involved, rat livers were stored for 1 h in UW solution with or without the addition of 1.4 microM nisoldipine (Miles, West Haven, Conn., USA). The liver grafts were investigated in vivo 90 min after transplantation by intravital fluorescence microscopy. Sinusoidal perfusion was reduced in all sublobular regions of the liver in the UW group (e.g. portal area: 76.7 +/- 2.1%) and in the nisoldipine group (85.8 +/- 1.5%). Diameters of liver sinusoids were comparably reduced in the UW and nisoldipine groups indicating that nisoldipine did not cause vasodilatation. Adhesion of leukocytes, however, rose significantly after liver transplantation particularly in periportal regions (25.8 +/- 2.5%) compared to controls (17.1 +/- 2.8%; P < 0.05). Adhesion of leukocytes was reduced when nisoldipine was included in UW solution (13.3 +/- 1.7%; P < 0.05). Administration of latex particles, which were given in additional experimental groups, demonstrated an impressive increase in phagocytic activity of Kupffer cells after liver transplantation in periportal and pericentral areas (161 +/- 14% and 184 +/- 19% of controls). Phagocytosis was significantly reduced by nisoldipine in the periportal region (101 +/- 10%; P < 0.01). Thus, the beneficial effect of nisoldipine was most pronounced in periportal regions, where the majority of Kupffer cells are located and leukocyte adhesion was at a maximum.

Reduction by superoxide dismutase of leukocyte-endothelial adherence after liver transplantation

One hour after orthotopic rat liver transplantation, hepatic microcirculation and adhesion characteristics of leukocytes to the endothelial wall were studied with intravital microscopy. Cold storage for 1 and 8 hours in Euro-Collins solution resulted in reduction of perfused sinusoids to 83% and 48% and a decrease of leukocyte velocity from 417 microns/sec in controls to 311 microns/sec and 269 microns/sec, respectively. Additionally, the number of permanently adherent leukocytes rose from 4% in controls to 33% and 43% after cold storage for 1 and 8 hours. Intravenous injection of the free radical scavenger human recombinant superoxide dismutase (40 mg/kg) during reperfusion resulted in marked improvement of the hepatic microcirculation after both 1 and 8 hours of cold storage (91% and 69% perfused sinusoids; 420 microns/sec and 350 microns/sec leukocyte velocity; p less than 0.05). Furthermore, the percentage of permanently adherent leukocytes decreased to 13% and 28% after 1 and 8 hours of cold ischemia, respectively. These results support the hypothesis that oxygen-derived free radicals contribute to leukocyte adherence and microcirculatory failure after cold liver ischemia and transplantation. Thus, application of oxygen free radical scavengers during liver transplantation procedures might be useful to improve graft function.