[Radiological evaluation of k-wire osteosynthesis, in comparison to fixed-angle-plate osteosynthesis, in patients aged 80 years or more with distal radius fractures]

BACKGROUND

This study evaluates the short-term radiological outcome of K-wire osteosynthesis (KWO) in comparison to the fixed-angle-plate osteosynthesis (ORIF) on distal radius fractures in elderly patients (aged 80 years or more) with osteoporotic bones.

PATIENTS AND METHODS

This study retrospectivly compares the postoperative X-rays of distal radius fractures (obtained between the years of 1998-2009) of patients aged 80 years and above treated with KWO (228 fractures, mean age 85 years), with the results of patients who were treated with fixed-angle plate ORIF (120 fractures, mean age 84 years). Within the KWO results, we also further compared the radiological results of a static and a dynamic (Kapandji) KWO technique. Only patients with a postoperative, anatomic reduction, and those who were radiologically followed up in a period of 2 months and above were included. The radiological criteria included the palmar and radial inclination as well as the radial shortening.

RESULTS

With KWO performed in a static technique, 24% of the postoperative results showed no reduction loss. The use of the dynamic Kapandji technique KWO, improved the positive results to 63%. However, almost a third of the fractures (30%) treated with KWO, had shifted back to their preoperative positions, or worsened overall. The fixed angle plate (ORIF) was able to maintain 76% of all fractures in their postoperative positions. Merely 1.7% of the ORIF group sustained a complete reduction loss. The fixed-angle plate osteosynthesis shows a significant decrease of cases in which a complete repositioning loss is experienced.

CONCLUSION

Although the importance of anatomic reconstruction of distal radius fractures is often debated in cases involving elderly patients, it is our considered opinion that, should an operative solution be chosen, one should consider the fixed-angle-plate osteosynthesis as the preferred operation method to prevent loss of reduction.

[Gunshot injuries--incidence and treatment]

BACKGROUND

Gunshot injuries are very rare in the European Union. To show the requirements for the trauma surgeon to deal with gunshot injuries this analysis was performed.

METHODS

Gunshot injuries seen at Lorenz Boehler Trauma Center from 1997 to 2004 were reviewed. The case histories of 67 patients were analysed for the cause of the gunshot injury, type of weapon, surgical intervention, days of treatment and outcome.

RESULTS

The most commonly cause of gunshot injuries were criminal offenses (n = 35). Handguns were used most often (n = 32). The locations of injuries were evenly distributed over head (n = 18 ), trunk (n = 16), upper (n = 15) and lower limb (n = 18). Surgical treatment was performed in 57 patients. The median stay on ICU was 10 days. 6 patients died.

CONCLUSION

Gunshot injuries are frequently not confined to the extremities. The challenge for the trauma surgeon is to deal with injuries of the head, chest and abdomen.

Nerve regeneration using tubular scaffolds from biodegradable polyurethane

INTRODUCTION

In severe nerve lesion, nerve defects and in brachial plexus reconstruction, autologous nerve grafting is the golden standard. Although, nerve grafting technique is the best available approach a major disadvantages exists: there is a limited source of autologous nerve grafts. This study presents data on the use of tubular scaffolds with uniaxial pore orientation from experimental biodegradable polyurethanes coated with fibrin sealant to regenerate a 8 mm resected segment of rat sciatic nerve.

METHODS

Tubular scaffolds: prepared by extrusion of the polymer solution in DMF into water coagulation bath. The polymer used for the preparation of tubular scaffolds was a biodegradable polyurethane based on hexamethylene diisocyanate, poly(epsilon-caprolactone) and dianhydro-D-sorbitol. EXPERIMENTAL MODEL: Eighteen Sprague Dawley rats underwent mid-thigh sciatic nerve transection and were randomly assigned to two experimental groups with immediate repair: (1) tubular scaffold, (2) 180 degrees rotated sciatic nerve segment (control). Serial functional measurements (toe spread test, placing tests) were performed weekly from 3rd to 12th week after nerve repair. On week 12, electrophysiological assessment was performed. Sciatic nerve and scaffold/nerve grafts were harvested for histomorphometric analysis. Collagenic connective tissue, Schwann cells and axons were evaluated in the proximal nerve stump, the scaffold/nerve graft and the distal nerve stump. The implants have uniaxially-oriented pore structure with a pore size in the range of 2 micorm (the pore wall) and 75 x 700 microm (elongated pores in the implant lumen). The skin of the tubular implants was nonporous. Animals which underwent repair with tubular scaffolds of biodegradable polyurethanes coated with diluted fibrin sealant had no significant functional differences compared with the nerve graft group. Control group resulted in a trend-wise better electrophysiological recovery but did not show statistically significant differences. There was a higher level of collagenic connective tissue within the scaffold and within the distal nerve stump. Schwann cells migrated into the polyurethane scaffold. There was no statistical difference to the nerve graft group although Schwann cell counts were lower especially within the middle of the polyurethane scaffold. Axon counts showed a trend-wise decrease within the scaffold.

CONCLUSION

These results suggest that biodegradable polyurethane tubular scaffolds coated with diluted fibrin sealant support peripheral nerve regeneration in a standard gap model in the rat up to 3 months. Three months after surgery no sign of degradation could be seen.

Bone mass after treatment of malignant lymphoma in childhood

BACKGROUND

Sex hormone deficiency, growth hormone deficiency, skeletal irradiation, and treatment with corticosteroids or methotrexate may all cause reduction in bone mass after treatment for childhood malignant lymphoma. Previous studies of the bone mass of childhood cancer survivors often lacked adequate local reference data, and survivors of malignant lymphoma were never analyzed separately.

PROCEDURE

The bone mass of survivors of childhood Hodgkin disease (n = 23) or non-Hodgkin lymphoma (n = 21) was measured by dual-energy X-ray absorptiometry a median of 11 years after diagnosis (range 2-25). Results were compared with local data on 463 healthy controls.

RESULTS

Adjusted for gender and age, the mean whole-body bone mineral content and bone mineral areal density were slightly, but significantly, reduced (0.5 and 0.4 SD lower than predicted). The reduced bone mineral content was associated with a significantly reduced height, whereas the size-adjusted bone mass (bone mineral content for bone area) did not differ significantly from that of controls. Lower height was related to male gender and to cranial, thoracic, and lumbar spine irradiation. Whole-body bone mineral content and bone mineral density were lower in persons treated with lumbar spine irradiation and whole-body bone mineral content was higher in nine women receiving sex hormone replacement therapy or oral contraceptives. Whole-body bone mass was not related to the cumulated doses of corticosteroids or methotrexate.

CONCLUSIONS

Eleven years after diagnosis of childhood Hodgkin disease or non-Hodgkin lymphoma, the whole-body bone mass of survivors was only slightly reduced and the size-adjusted bone mass was normal.

Growth hormone response to a growth hormone-releasing hormone stimulation test in a population-based study following cranial irradiation of childhood brain tumors

Children with brain tumors are at high risk of developing growth hormone deficiency (GHD) after cranial irradiation (CI) if the hypothalamus/pituitary (HP) axis falls within the fields of irradiation. The biological effective dose (BED) of irradiation to the HP region was determined, since BED gives a means of expressing the biological effect of various irradiation treatment schedules in a uniform way. Hypothalamic versus pituitary damage as cause of GHD was distinguished in 62 patients by comparing the growth hormone (GH) peak response to an insulin tolerance test (ITT)/arginine stimulation test and the GH response to a growth hormone-releasing hormone (GHRH) stimulation test. Peak GH response to a GHRH test was significantly higher (median 7.3 mU/l; range: 0.5--79.0 mU/l) than that of an ITT/arginine test (median 4.7 mU/l; range: 0.01--75.0 mU/l) (p = 0.017). Peak GH after a GHRH test was significantly inversely correlated to follow-up time (r(s) = -0.46, p < 0.0001) and to BED (R(s) = -0.28, p = 0.03), and both were found to be of significance in a multivariante regression analysis. We speculate that a significant number of patients developed hypothalamic radiation-induced damage to the GHRH secreting neurons, and secondary to this the pituitary gland developed decreased responsiveness to GHRH following CI in childhood.

Gonadal status in male survivors following childhood brain tumors

The effect of radiotherapy (RT) and chemotherapy (CT) on gonadal function was assessed in males treated for a childhood brain tumor not directly involving the hypothalamus/pituitary (HP) axis in a population-based study with a long follow-up time. All males <15 yr at the time of diagnosis (median: 9.0 yr, range: 0.8 to 14.9 yr) and diagnosed from January 1970 through February 1997 in the eastern part of Denmark and [gte]18 yr at the time of follow-up (median: 25.8 yr, range:18.5 to 39.3 yr) were included. Thirty males fulfilled the criteria. The median age at time of RT was 9.0 yr (range: 0.8 to 14.9 yr) and the median length of follow-up was 18 yr (range: 2.0 to 28.0 yr). The biological effective dose of RT was determined to the HP region and to the spine and expressed in gray because the biological effective dose gives a means of expressing the biological effect on normal tissue of different dosage schedules in a uniform way. Levels of serum FSH, luteinizing hormone (LH), sexual hormone-binding globulin, testosterone, and inhibin B were measured and compared with healthy age-matched male controls (n = 347), and the patients had a GnRH stimulation test performed with determination of peak FSH and LH. Patients treated with RT + CT (n = 13), compared with patients treated with RT only (n = 17), had significantly higher median peak FSH (8.33 vs. 3.79 IU/L, P = 0.03) and median peak LH (20.0 vs. 12.8 IU/L, P = 0.03), and significantly lower median inhibin B (86.0 vs. 270 pg/ml, P = 0.03), and median inhibin B/FSH ratio (12.8 vs. 107.9, P = 0.04), which indicates gonadal damage. Inhibin B and inhibin B/FSH ratio were also significantly lower in the RT + CT group, compared with controls (median: 86.0 vs. 215 pg/ml, P = 0.02), (median:12.8 vs. 67; P = 0.01), respectively. We found a significantly inverse correlation between basal FSH and inhibin B and FSH and total testicular volume (r(s) = -0.83; P < 0.0001), (r(s) = -0.67; P < 0.0001), respectively, and a significant correlation between inhibin B and total testicular volume (r(s) = 0.63; P < 0.0001). Stepwise backward multiple linear regression analysis showed the best-fit model to predict inhibin B levels included total testicular volume (P = 0.002) and CT (P = 0.09). Median basal LH in the RT-only group was significantly lower, compared with controls (3.44 vs. 2.45 IU/L; P = 0.0001) indicating secondary hypogonadism, and in both the RT + CT group and the RT-only group, levels of testosterone were significantly lower, compared with our reference population (12.8 vs. 21.9 nmol/L; P = 0.001, and 14.7 vs. 21.9 nmol/L; P = 0.0003), respectively. In conclusion these data suggest that cranial irradiation for a childhood brain tumor may affect the HP axis, and adjuvant CT can reduce inhibin B indicating primary gonadal damage. Thus, such patients may have normal or even low levels of FSH despite damage to the seminiferous epithelium, and because the fertility status by a semen analysis for psychological reasons can be difficult to obtain in this group of patients, we suggest inhibin B as the most useful direct serum marker of spermatogenesis in the follow-up of individuals who have received both cranial irradiation and gonadotoxic chemotherapy. However, because the number of patients with RT + CT and RT only are small, these data must be confirmed in further studies.

Degree of fatness after allogeneic BMT for childhood leukaemia or lymphoma

Excess fatness is frequent after childhood ALL treated without BMT. We measured the whole-body percent fat by dual-energy X-ray absorptiometry and the body-mass index (weight/height(2) (kg/m(2)), BMI) in 25 survivors of childhood leukaemia or lymphoma (21 with ALL) who had received TBI and allogeneic BMT a median of 8 years ago (range 4-13). Adjusted for sex and age, the mean BMI was slightly but significantly reduced (0.4 s.d. below predicted) and the whole-body percent fat was significantly increased compared with healthy controls (1.1 s.d. above predicted). Eleven of 25 patients had a percent fat above the 90 percentile of the reference values, which indicates excess fatness. Adjusted for sex and age, a higher percent fat was related to additional cranial irradiation. Controlled for this, the whole-body percent fat seemed to be unrelated to age at BMT, length of follow-up, and previous chemotherapy. Compared with untransplanted ALL survivors treated with cranial irradiation, BMT survivors had significantly reduced BMI but similar whole body percent fat. BMI was a poor measure of body fatness in these patients. In conclusion, survivors of BMT for childhood leukaemia or lymphoma are adipose and slightly underweight and consequently have a substantially reduced lean body mass.

[Callus development after bored and unbored femoral interlocking nailing. An experimental study]

This was a prospective randomized baboon animal study, the study protocol was approved by the ethical committee according to the international guidelines for animal research projects. In 8 animals a midschaft femoral osteotomy was stabilized with reamed femoral interlocking nailing and in 8 animals by unreamed locked femoral nailing. Polychrome sequence bone labeling was done 5 weeks postop. with calcein-green, 8 weeks postop. with xylenol-orange and 10 weeks postop. with oxytetracycline. 10 weeks postop. the animals were sacrificed, the femurs explanted and planimetric and epifluorescence histomorphometric evaluation of serial transverse sections were done. In planimetric histomorphometric evaluation in unreamed femoral nailing a mean endostal callus formation was recorded with 28.0 +/- 9.9 mm2 per section and in reamed femoral nailing with 11.5 +/- 5.0 mm2 (p < 0.001). Periostal callus formation was recorded in the unreamed group with 238.7 +/- 87.1 mm2 per section and in the reamed group with 142.1 +/- 71.9 mm2 (p < 0.001). In epifluorescence histological evaluation endostal as well as periostal callus formation was more extensive and earlier after unreamed than reamed femoral nailing. Endostal callus formation was found in all animals after unreamed femoral nailing, and was present in 2 out of 8 specimen in the reamed group. Also 1 out of 8 animals in the reamed group developed a non-union. Unreamed femoral nailing with low diameter interlocking nails proved to be safe regarding bone healing in this experimental model with obvious advantages both in amount and time course of callus formation compared to reamed femoral nailing. Based on this results unreamed femoral nailing techniques can be recommended for femoral fractures.

Second malignant neoplasms after cancer in childhood and adolescence: a population-based case-control study in the 5 Nordic countries. The Nordic Society for Pediatric Hematology and Oncology. The Association of the Nordic Cancer Registries

Our purpose was to assess the risk of developing a second malignant neoplasm (SMN) after cancer in childhood and adolescence associated with different treatment modalities. Our investigation was performed as a nested case-control study within a Nordic cohort of 25,120 patients younger than 20 years old at first malignant neoplasm (FMN) diagnosed in 1960 through 1987. SMNs were diagnosed in 1960 through 1991. For each case of SMN, 3 controls were sampled, matched by sex, age, calendar year of diagnosis and length of follow-up. For the final analysis, there were 234 cases and 678 controls. Relative risks (RRs) of various exposures were estimated by means of conditional logistic regression, with non-exposed as the reference. The RR of developing SMN in the radiated volume was 4.3 (95% confidence interval 3.0-6.2). The risk was highest in children diagnosed before the age of 5 years; it increased with the dose of radiation and with increasing follow-up time after FMN. Chemotherapy alone was not associated with an increased RR, but it significantly potentiated the effect of radiotherapy. RRs were unchanged between the periods 1960-1973 and 1974-1987, and since the use of chemotherapy increased in the latter period, the number of SMNs may increase. Hereditary factors were important for the occurrence of SMN independently of therapy. We conclude that radiation was the most important treatment-related risk factor for the development of SMN. Chemotherapy appeared to play only an accessory role during the study period, potentiating the carcinogenic effect of radiotherapy.

Cranial radiotherapy of childhood brain tumours: growth hormone deficiency and its relation to the biological effective dose of irradiation in a large population based study

OBJECTIVE

The study was to determine the incidence of GH deficiency (GHD) following cranial radiotherapy (RT) for a childhood brain tumour in a large population based study and analyse the biological effective dose (BED) to the hypothalamus/pituitary (HP) region as a risk factor.

DESIGN

BED was assessed by use of the linear-quadratic (LQ) model, which gives a means of expressing the biological effect of various treatment schedules in a uniform way. In patients aged >/= 18 years (n = 53) GH status was assessed by an insulin-tolerance test (ITT) (n = 34), however, in patients with seizure disorders (n = 19), and in 20 children aged < 18 years GH status was assessed by an arginine test. Cut-off levels for GHD, indicating GH substitution, were defined by a peak GH response of < 9 mU/l and < 15 mU/l for patients >/= 18 and < 18 years, respectively.

PATIENTS

Ninety-one children aged < 15 years eligible for the study, diagnosed between 1970 and 1997 in the Eastern part of Denmark, the Faroe Islands and Greenland, with a primary brain tumour not directly involving the HP axis. 84% (n = 76) agreed to participate. Three patients were excluded due to hypothyroidism detected at time of testing.

MEASUREMENTS

Serum GH and levels of serum insulin-like growth factor-I (s-IGF-I) and serum insulin-like growth factor binding protein-3 (s-IGFBP-3) were measured. BED was assessed to the HP region.

RESULTS

The median age at the time of RT was 8.7 years (range: 0.8-14.9 years) and the median time of follow-up was 15 years (range: 2-28 years). Fifty-eight patients (80%) had GHD and they had received a median BED of 77.5 Gy to the HP region, whereas the median BED was 54.5 Gy for 15 patients without GHD (P = 0.002). Peak GH and BED were correlated (rs = -0.53, P < 0001). Median IGF-I SDS and IGFBP-3 SDS were -2.5 (-5.2-0.7 SDS) and -1.7 (-5.8-0.9 SDS), respectively, and IGF-I SDS was correlated to peak GH (rs = 0.45, P < 0.001). Peak GH and length of follow-up were related (rs = -0.28, P = 0.018). Stepwise backward multiple linear regression analysis showed that the best-fit model to predict the peak GH release following ITT/arginine stimulation included BED (P < 0.0001) and length of follow-up (P = 0.05).

CONCLUSIONS

The data of this study suggest that the majority of long-term survivors of brain tumours develop GH deficiency following radiotherapy in childhood and that the adverse effects of radiotherapy may be directly related to the biologically effective dose. With longer follow-up fewer patients might respond normally to GH stimulation tests.

[Unreamed antegrade humeral interlocking nailing]

In a prospective clinical study 111 fractures of the humerus in 109 consecutive patients were stabilized with unreamed antegrade interlocking nailing. 97 patients were evaluated with individual follow-up, in the mean at 24.2 months postoperatively. Mean fracture consolidation time was 12.3 weeks (9-16 weeks). Five patients presented a non union. At follow-up 19 patients had a limitation in motion of the shoulder, in the mean with 20% compared to the opposite side. Eight patients had permanent shoulder pain, in nine patients shoulder pain occurred during manual strain of the upper limb. Neither limitation of motion nor pain at the elbow region was present in all cases at follow-up. Ultrasound examination revealed in six cases a lesion of the rotator cuff, which was linked in these cases with permanent pain at the shoulder joint. In five patients a prominent nail tip at the entrance point caused a lesion of the rotator cuff with impingement syndrome. Eight out of nine preoperative palsies of the radial nerve recovered within a mean period of 4.3 months without operative measurements. Unreamed antegrade interlocking nailing of humeral fractures is a safe technique regarding consolidation rate with advantages regarding early mobilization of the upper limb. Careful suturing of the rotator cuff and countersinking of the proximal nail tip at the entrance point is a prerequisite in avoiding permanent lesions of the rotator cuff and shoulder pain.

Bone mass after allogeneic BMT for childhood leukaemia or lymphoma

The bone mass was measured by dual energy X-ray absorptiometry in 25 survivors of childhood leukaemia or lymphoma (21 with ALL) who had received TBI and allogeneic BMT a median of 8 years ago (range 4-13). Results were compared with local data on 463 healthy controls and 95 survivors of childhood ALL treated without BMT. Adjusted for sex and age, the mean whole-body bone mineral content (BMC) and bone mineral areal density were significantly less than in healthy controls (0.8 and 0.5 s.d. less than predicted). The reduced BMC was caused by a significantly reduced height for age, whereas bone area for height and BMC for bone area were similar to controls. Less bone mass tended to be related to additional cranial irradiation and age above 20 years at follow-up. Controlled for this, the whole-body bone mass seemed to be unrelated to previous chemotherapy and endocrine status at follow-up and tended to be only marginally less in BMT patients than in ALL survivors treated without BMT. In conclusion, 8 years after allogeneic BMT for childhood leukaemia or lymphoma, the whole-body bone mass was only slightly reduced and the size-adjusted bone mass (BMC for bone area) was normal. Bone Marrow Transplantation (2000) 25, 191-196.

Dosimetry and growth hormone deficiency following cranial irradiation of childhood brain tumors

BACKGROUND

Dosimetry of the hypothalamus-pituitary (HP) region could allow prediction of the risk of growth hormone deficiency (GHD) following cranial irradiation.

PROCEDURE

Nineteen children (15 boys) with a median age of 6.3 years (range 1.7-16.5) at the time of irradiation of a brain tumor not involving the HP axis were followed for 1.2-6.3 years (median 3.4) from radiotherapy (RT). The dose to a standardized anatomical model including the HP region was calculated from dose-volume histograms of 10% to 100% in steps of 10% of the HP model based on data from a computer-based treatment planning system. If GHD was suspected from insulin-like growth factor-I, serum insulin-like growth factor binding protein-3, and/or height velocity measurements, an arginine stimulation test was performed. GHD was defined by a peak GH <15mU/liter.

RESULTS

Ten patients developed GHD 10-26 months from irradiation. Cox regression analysis identified the 90% dose-volume of the HP box as the strongest predictor of development of GHD (P = 0.03). The median dose to the 90% dose-volume of the HP region was 37.5 Gy (range 2. 3-55.3). The cumulated risk of GHD 2.5 years after radiotherapy for children receiving more than and less than 37.5 Gy to the HP region was 87% and 33%, respectively (P = 0.036).

CONCLUSIONS

Dosimetry of a defined HP volume provides the opportunity to 1) calculate the exact dose delivered to this region, 2) predict the risk of GHD and, 3) in the future revise the treatment planning and thus reduce the risk of endocrine adverse effects.

Degree of fatness after treatment for acute lymphoblastic leukemia in childhood

Excessive fatness is considered a frequent late complication of treatment for childhood acute lymphoblastic leukemia. Most previous studies, however, were based on body mass index (BMI) rather than more direct fat mass measurements. We studied 95 survivors of childhood acute lymphoblastic leukemia a median of 11 yr (range, 3-23 yr) after diagnosis. BMI values at diagnosis, at cessation of therapy, yearly thereafter for up to 10 yr, and at follow-up were compared with French reference values. Whole body percent fat was measured at follow-up by dual energy x-ray absorptiometry and compared with data from 463 local controls. Adjusted for sex and age, the mean BMI increased significantly during therapy and remained largely unchanged thereafter. At follow-up, BMI did not differ significantly between patients and local controls. On the other hand, the whole body percent fat was significantly increased (mean observed/predicted value, 21.8/19.0%; P < 0.0002). Twenty-five patients (26%) had a percent fat above the 90th percentile of the reference values, which indicates excessive fatness. Adjusted for sex and age, a higher percent fat was related to cranial irradiation or GH insufficiency, but not to sex, the cumulative doses of anthracyclines or corticosteroids, or the type of corticosteroid used. BMI was a poor measure of body fatness.

Insulin-like growth factor-I and insulin-like growth factor binding protein-3 during maintenance chemotherapy of acute lymphoblastic leukemia in children

PURPOSE

To assess the effect of maintenance chemotherapy (MT) on growth factors and growth in children with acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

Twenty-one children (10 girls, 11 boys) with standard risk pre-B ALL treated with chemotherapy had serum insulin-like growth factor-I (IGF-I), serum IGF binding protein-3 (IGFBP-3) levels, and linear growth and weight data measured every 3 months during MT. The levels of the cytotoxic metabolites of methotrexate (MTX) and 6-mercaptopurine (6MP) (i.e., erythrocyte MTX polyglutamates [E-MTX], and erythrocyte 6-thioguanine nucleotides [E-6TGN]), s-aminotransferases, and white blood counts (WBC) were measured at least monthly.

RESULTS

At the beginning of MT, the median IGF-I standard deviation scores (SDS) and IGFBP-3 SDS were -0.52 and -0.09, respectively, which declined during MT to -1.67 (P < 0.001) and -1.82 (P < 0.001), respectively. At the time of diagnosis, the median height SDS was -0.4, which declined during MT to a median height SDS of -0.9 at cessation of therapy. No significant correlations were found between growth factor levels, growth and body mass index (BMI) versus the doses of MTX, and 6MP, E-MTX, E-6TGN, s-aminotransferases, or WBC.

CONCLUSIONS

A significant decline in IGF-I, IGFBP-3, and growth retardation may not be directly related to the treatment intensity during MT.

Intramedullary pressure and bone marrow fat extravasation in reamed and unreamed femoral nailing

This study was designed to investigate whether intramedullary pressure and embolization of bone marrow fat are different in unreamed compared with conventional reamed femoral nailing in vivo. In a baboon model, the femoral shaft was stabilized with interlocking nailing after a midshaft osteotomy. Intramedullary pressure was measured in the distal femoral shaft fragment at the supracondylar region. Extravasation of bone marrow fat was determined by the modified Gurd test (range: 0-5) with blood samples from the vena cava inferior. Data were monitored in eight unreamed and eight reamed intramedullary femoral nailing procedures. Intramedullary pressure increased in the unreamed group to 76 +/- 25 mm Hg (10.1 +/- 3.3 kPa) during insertion of 7-mm nails and in the reamed group to 879 +/- 44 mm Hg (117.2 +/- 5.9 kPa) during reaming of the medullary cavity. Insertion of 9-mm nails after the medullary cavity had been reamed to 10 mm produced an intramedullary pressure of 254 +/- 94 mm Hg (33.9 +/- 12.5 kPa) (p < 0.05). Fat extravasation in the unreamed group was recorded with a score of 2.9 +/- 0.4 for the Gurd test during nailing with 7-mm nails, whereas in the reamed group significantly more fat extravasation was noticed during the reaming procedures, with a score of 4.6 +/- 0.1. Liberation of fat during insertion of 9-mm nails after reaming was recorded with a score of 3.5 +/- 0.4. In both groups, a positive correlation of fat extravasation with the rise in intramedullary pressure was found (reamed group: r(s) = 0.868; unreamed group: r(s) = 0.698), resulting in significantly less liberation of bone marrow fat in the unreamed stabilized group than in the reamed control group (p < 0.05). The data indicate that fat embolization during nailing procedures after femoral osteotomy increases with increasing intramedullary pressure and occurs in a lesser degree in unreamed than in reamed intramedullary femoral shaft stabilization.

Ultrasound B-mode changes in the uterus and ovaries and Doppler changes in the uterus after total body irradiation and allogeneic bone marrow transplantation in childhood

Internal genitalia and uterine blood flow were assessed by ultrasound in 12 females 4.0-10.9 years after total body irradiation and allogeneic bone marrow transplantation for childhood leukaemia or lymphoma. Median age of the participants was 12.7 years (range 6.1-17.6) at bone marrow transplantation and 21.5 years (11.6-25.6) at the follow-up study. At follow-up all had entered puberty and 11/12 females had experienced the menarche. Eight females received sex steroid replacement therapy, three had spontaneous pubertal development and one woman experienced symptoms of estrogen deficiency. Median uterine and ovarian volumes were significantly reduced to -2.6 standard deviation scores (SDS) (-6.3 to -0.6), P = 0.002, and -2.6 SDS (-4.8 to -0.5), P = 0.002, respectively, compared with normal controls. Follicles were only detectable in two individuals. Uterine blood flow was impaired, as a systolic blood flow could be measured in 6/9 individuals, and a diastolic blood flow in 1/9 females. Our results indicate that the prescribed dosage of hormone replacement therapy, which was sufficient to induce bleeding and suppress other stigmata of premature menopause, was inadequate to generate normal uterine growth. In order to achieve uterine growth higher doses of hormone replacement therapy may be required. Our results confirm pelvic ultrasound as a reliable tool for investigation of internal female genitalia; however, in an infertility setting further tests are indicated.

Bone mass and body composition after cessation of therapy for childhood cancer

Our aim was to review current information on body composition and bone mass after cessation of therapy for childhood cancer and to present preliminary data on body composition and bone mass in a group of Danish survivors of childhood leukaemia or lymphoma. Elevated body-mass index (weight/height2; BMI) is frequent after treatment for childhood acute lymphoblastic leukaemia. BMI increases during therapy or within the first year after therapy and remains abnormal thereafter. Treatment with corticosteroids, abnormal growth-hormone secretion after treatment with cranial irradiation (CI) or corticosteroids, younger age at diagnosis, or female gender were risk factors for elevated BMI in earlier studies. We evaluated 185 survivors of childhood leukaemia or lymphoma by dual-energy X-ray absorptiometry scanning. We found elevated whole-body relative fat mass, which was associated with CI. Other studies found reduced bone mass in the radius, the lumbar spine and the whole body after treatment for childhood cancer. Growth-hormone deficiency that is not adequately corrected, CI, reduced height or reduced weight were risk factors for reduced bone mass. In our 185 participants, the whole-body bone mass was also reduced significantly compared with reference values. CI and older age at follow-up were risk factors for reduced bone mass. We conclude that the elevated relative fat mass and reduced bone mass seen after treatment for childhood leukaemia or lymphoma is associated mainly with CI.

Bone mass after treatment for acute lymphoblastic leukemia in childhood

PURPOSE

To study bone mass after childhood acute lymphoblastic leukemia (ALL) and determine if reduced bone mass is related to previous therapy or endocrine status at follow-up.

PATIENTS AND METHODS

We studied 95 survivors of childhood ALL who were in first remission a median of 11 years (range, 3 to 23 years) after diagnosis and who had never been irradiated outside a cranial field. The bone mass was measured by dual-energy x-ray absorptiometry. The results were compared with data on 396 local controls.

RESULTS

Adjusted for sex and age, the mean whole-body bone mineral content (BMC) and bone mineral areal density (BMDA) were both significantly reduced (0.4 SDs less than the predicted mean value). This was mainly caused by reduced bone mass in the 33 participants who were aged 19 years or older at follow-up. In these young adults, the mean height for age, bone area for height, and BMC for bone area were all significantly reduced. This indicated that the reduced whole-body bone mass was caused by both reduced bone size and reduced size-adjusted bone mass. Reduced bone size was related to previous cranial irradiation. Reduced size-adjusted bone mass was not significantly related to age at diagnosis or at follow-up, length of follow-up, cranial irradiation, cumulative dose of methotrexate or corticosteroids, or endocrine status at follow-up.

CONCLUSION

The whole-body bone mass was reduced 11 years after diagnosis of childhood ALL. If these abnormalities remain, survivors of childhood ALL will have an increased risk for osteoporotic fractures later in life.

Pulmonary function after treatment for acute lymphoblastic leukaemia in childhood

The aim of this study was to examine pulmonary function after acute lymphoblastic leukaemia in childhood and identify risk factors for reduced pulmonary function. We studied a population-based cohort of 94 survivors of acute lymphoblastic leukaemia in childhood who were in first remission after treatment without spinal irradiation or bone marrow transplantation. Pulmonary function test results were compared with reference values for our laboratory, based on 348 healthy subjects who had never smoked from a local population study. A median of 8 years after cessation of therapy (range 1-18 years) the participants had a slight, subclinical, restrictive ventilatory insufficiency and reduced transfer factor and transfer coefficient. The changes in lung function were related to younger age at treatment and to more dose-intensive treatment protocols that specified more use of cranial irradiation and higher cumulative doses of anthracyclines, cytosine arabinoside and intravenous cyclophosphamide than previous protocols. We conclude that, 8 years after treatment without bone marrow transplantation or spinal irradiation, survivors of childhood acute lymphoblastic leukaemia in first remission were without pulmonary symptoms but had signs of slight restrictive pulmonary disease including reduced transfer factor. The increased dose intensity of many recent protocols for childhood acute lymphoblastic leukaemia may lead to increased late pulmonary toxicity.

Risk of cancer among offspring of childhood-cancer survivors. Association of the Nordic Cancer Registries and the Nordic Society of Paediatric Haematology and Oncology

BACKGROUND

Increasing numbers of children with cancer survive and reach reproductive age. However, the risk of cancer (other than retinoblastoma) in the offspring of survivors of childhood and adolescent cancer is uncertain.

METHODS

Using data from national cancer and birth registries, we assessed the risk of cancer among 5847 offspring of 14,652 survivors of cancer in childhood or adolescence diagnosed since the 1940s and 1950s in Denmark, Finland, Iceland, Norway, and Sweden. The offspring were followed up for a diagnosis of cancer for 86,780 person-years, and standardized incidence ratios were calculated.

RESULTS

Among the 5847 offspring, 44 malignant neoplasms were diagnosed (standardized incidence ratio, 2.6; 95 percent confidence interval, 1.9 to 3.5). There were 17 retinoblastomas, yielding a standardized incidence ratio of 37. There were 27 neoplasms other than retinoblastoma (standardized incidence ratio, 1.6; 95 percent confidence interval, 1.1 to 2.4). The second most common primary site of cancer among the offspring was the brain and nervous system, in which eight tumors were observed (standardized incidence ratio, 2.0; 95 percent confidence interval, 0.9 to 3.9.) There were between zero and four apparently sporadic cases of cancer in other primary sites among the offspring. Excluding 4 likely cases of hereditary cancer and 2 subsequent cancers among the offspring with hereditary retinoblastoma, there were 22 sporadic cancers, for a standardized incidence ratio of 1.3 (95 percent confidence interval, 0.8 to 2.0).

CONCLUSIONS

There is no evidence of a significantly increased risk of nonhereditary cancer among the offspring of survivors of cancer in childhood.

Risk factors for reduced pulmonary function after malignant lymphoma in childhood

The aim was to study pulmonary function after Hodgkin disease or non-Hodgkin Lymphoma in childhood and to evaluate if younger age at diagnosis and therapy is a risk factor for reduced pulmonary function. We studied a population-based sample of survivors of Hodgkin disease (n = 22) or non-Hodgkin lymphoma (n = 19) in childhood. Pulmonary function test results were compared with reference values for our laboratory, generated by adjusting published reference values fit 348 healthy never-smokers from a local population study. Data were analyses as standardised residuals, which are [observed minus predicted value] divided by the residual standard deviation of the reference equations. At a median of 11 years after diagnosis (range 2 to 24), the participants had significantly reduced lung volumes and transfer factor, unrelated to the few pulmonary symptoms. On average, the total lung capacity was reduced to -0.9 standardised residual and the transfer factor was reduced to -1.3 standardised residual. Young age at therapy seemed to be a risk factor for reduced lung function, especially when treatment included thoracic irradiation. No significant toxic synergism was observed between smoking and previous cancer therapy. Therapy without thoracic irradiation but with doxorubicin and cyclophosphamide was almost as toxic to lung function as therapy with thoracic irradiation but without doxorubicin and cyclophosphamide. In conclusion, lung volumes and transfer factor were reduced several years after childhood Hodgkin disease of non-Hodgkin lymphoma, with young age at therapy as a risk factor, especially when combined with thoracic irradiation.

Relationship between cumulative anthracycline dose and late cardiotoxicity in childhood acute lymphoblastic leukemia

PURPOSE

Late anthrocycline cardiotoxicity after treatment for childhood cancer is common and often progressive. A safe anthracycline dose that will not result in late cardiac abnormalities has not been established due to the limited dose ranges used in existing studies.

PATIENTS AND METHODS

To determine the relationship between cumulative anthracycline dose and late cardiotoxicity, we performed echocardiograms on 189 survivors of childhood acute lymphoblastic leukemia a median of 8.1 years (range, 2.0 to 23.4) after completion of anthracycline therapy. Patients were treated according to protocols that used widely varying cumulative anthracycline doses, but comparable nonanthracycline chemotherapy. Patients were divided into four groups based on the city of treatment and cumulative anthracycline dose: Copenhagen, 0 to 23 mg/m2 (n = 32); Boston, 45 mg/m2 (n = 17); Copenhagen, 73 to 301 mg/m2 (n = 53); and Boston, 244 to 550 mg/m2 (n = 87). Left ventricular dimension and fractional shortening were adjusted for sex and age or body-surface area through use of a control population (n = 296), and then compared among the four groups.

RESULTS

Mean left ventricular dimension was significantly increased in the high-dose Boston group (observed:predicted value, 4.57 cm:4.45 cm; P = .002) and significantly higher than in the two Copenhagen groups. In the three lower-dose groups, there was no significant increase in mean left ventricular dimension, and the groups were not significantly different from each other. Similarly, the mean left ventricular fractional shortening was significantly depressed in the high-dose Boston group (observed:predicted value, 29.0%:33.8%; P = .0001) and significantly lower than in the three lower-dose groups.

CONCLUSION

Depressed left ventricular fractional shortening and left ventricular dilatation were uncommon years after treatment of childhood leukemia when cumulative anthracycline doses were < or = 300 mg/m2.

Cancer in the offspring of parents with lung cancer

Despite several studies on the role of passive smoking in the development of childhood cancer, particularly leukaemia, lymphomas and brain cancer, no definitive answer has yet been provided. The aim of the cohort study reported here was to analyse the incidence of cancer in the offspring of young lung cancer patients on the basis of the assumption that all of the offspring were exposed passively to smoke. The files of the Danish Cancer Registry provided 3348 cases of lung cancer patients born after 1935, and their offspring (n = 6417) were identified through the Danish Population Register. The files of the offspring were then linked with the files of the Danish Cancer Registry and the numbers of cancers observed in the offspring were compared with those expected from national age-specific and calendar-time-specific rates. A total of 135,333 person-years was the basis for analysis. Twenty-six cancers were observed, with 30.3 expected, yielding a standardised incidence ratio (SIR) of 0.9 (90% confidence interval (CI), 0.6-1.2). There was no excess of brain tumours, leukaemias or lymphomas. Stratification for sex of the lung cancer patients revealed a non-significantly increased risk for both non-Hodgkin's lymphoma (three cases; SIR = 3.4; 90% CI: 0.9-8.7) and Hodgkin's disease (three cases; SIR = 2.6; 90% CI: 0.7-6.6) in the offspring of female lung cancer patients. These results suggest that there is little evidence of an excess cancer risk in childhood, whether due to passive smoking or to as yet unidentified genetic factors, among the offspring of people who develop lung cancer. However, the results are limited by the fact that exposure was only assessed indirectly, with no measurement of actual cigarette consumption made.

Intramedullary pressure and bone marrow fat intravasation in unreamed femoral nailing

OBJECTIVE

To investigate whether intramedullary pressure and bone marrow fat embolization are different in unreamed compared with conventional reamed femoral nailing. The null hypothesis is that there is no difference between the two techniques.

DESIGN

A prospective consecutive nonrandomized clinical trial.

METHODS

Intramedullary pressure was measured in the distal femoral fracture fragment at the supracondylar region. Bone marrow fat intravasation was measured by means of the modified Gurd-test. Monitoring was carried out in 31 unreamed and eight reamed intramedullary femoral nailing procedures.

RESULTS

Intramedullary pressure increased in the unreamed group to 82 +/- 11 mm Hg during the insertion of 9-mm and 10-mm nails and in the reamed group to 396 +/- 85 mm Hg during reaming of the medullary cavity. Insertion of nails after reaming led to an increase in intramedullary pressure of 79 +/- 13 mm Hg. A positive correlation between fat intravasation and intramedullary pressure was found in each group (rs = 0.73), resulting in less liberation of bone marrow fat in the unreamed group than in the reamed group.

CONCLUSIONS

Intramedullary pressure increased significantly in the reamed more than in the unreamed group. Bone marrow fat intravasation depended on the rise in intramedullary pressure, and occurred less frequently in unreamed than in reamed intramedullary femoral fracture stabilization.

Childhood leukemia following phototherapy for neonatal hyperbilirubinemia (Denmark)

To test the hypothesis that exposure to high intensity lightning (around 400 nanometers) in neonatal nurseries increases the incidence of childhood leukemia, over 55,120 newborn children treated with phototherapy for hyperbilirubinemia were identified from the Danish Hospital Discharge Register for 1977-89. Linkage of the roster with the national cancer registry through 1991 revealed 87 childhood cancers, whereas 85 were expected from the rates for the general population. The incidence of leukemia in 34 children was not unusual (standardized incidence ratio [SIR] = 1.2, 95 percent confidence interval [CI] = 0.8-1.7). Subgroup analyses revealed no remarkable patterns for any category of leukemia subtype, gender, or age at diagnosis. We conclude that whole-body exposure to phototherapy (420-470 nm) shortly after birth is not a significant risk factor for childhood leukemia.

Growth, growth hormone and final height after BMT. Possible recovery of irradiation-induced growth hormone insufficiency

The aim of the present study was to assess growth, final height, growth hormone (GH) secretion and growth factors after BMT including TBI in childhood. The median age of the 25 participants was 11.3 years at BMT, and a median of 7.5 years had elapsed since BMT. The median height standard deviation score (SDS) declined significantly from diagnosis until 4 years after BMT (n = 25, P = 0.015), and decreased 1.08 SDS from diagnosis until final height (n = 14, P = 0.030). Sitting height to standing height ratio was impaired, -0.64 SDS, P < 0.05. GH insufficiency was found in 32% at follow-up. Repeated assessments of GH production over the years indicated improvement in GH secretion in nine individuals. Evaluation of spontaneous 24-h GH secretion indicated a secretory pattern similar to controls, although the total amount of GH secreted was lower. Neither insulin-like growth factor-1 (IGF-1) nor IGF binding protein-3 (IGFBP-3) alone could be used as a marker of GH insufficiency. IGF-1 was low: -1.18 SDS; (P < 0.001). In conclusion, our study demonstrated the impact on growth, final height, body proportions, GH secretion and growth factors after BMT including TBI. We hypothesize that children who receive BMT at a younger age are more at risk of loss of final height and abnormal body proportions. Our data indicate that some improvement in GH production may occur over the years.

Lung function after allogeneic bone marrow transplantation for leukaemia or lymphoma

Longitudinal data were analysed on the lung function of 25 of 29 survivors of childhood leukaemia or lymphoma, who had been conditioned with cyclophosphamide and total body irradiation before allogeneic bone marrow transplantation, to test whether children are particularly vulnerable to pulmonary damage after transplantation. None developed chronic graft-versus-host disease. Transfer factor and lung volumes were reduced immediately after bone marrow transplantation, but increased during the following years. However, at the last follow up, 4-13 years (median 8) after transplantation, patients had significantly reduced transfer factor, total lung capacity, and forced vital capacity (-1.0, -1.2, and -0.8 SD score, respectively), and increased ratio of forced expiratory volume in one second to forced vital capacity (+0.9 SD score). None of the patients had pulmonary symptoms, and changes were unrelated to their age at bone marrow transplantation. In conclusion, patients had subclinical restrictive pulmonary disease at a median of eight years after total body irradiation and allogeneic bone marrow transplantation.

[Technique, results and risks of endoscopic carpal tunnel release]

Endoscopic carpal tunnel release was performed in 168 cases of carpal tunnel syndrome using the two-portal technique described by Chow. There were 164 cases of idiopathic carpal tunnel syndrome and four cases following a wrist trauma. Sensory symptoms improved within few days in 113 patients (67%) and in 141 cases within eight weeks (84%). Nighttime pain relief was achieved immediately in 87% of the patients and in 94% within eight weeks. Grip strength increased to preoperative values within eight weeks and pinch strength reached preoperative levels within six weeks. In four cases an iatrogenic injury of the superficial palmar vascular arch occurred. In another four patients, open revisional surgery had to be performed. Three of these patients presented an incomplete release of the retinaculum flexorum and in one patient a remaining part of the palmar fascia led to further compression of the median nerve despite complete dissection of the carpal ligament.

Risk of subsequent malignant neoplasms among 1,641 Hodgkin's disease patients diagnosed in childhood and adolescence: a population-based cohort study in the five Nordic countries. Association of the Nordic Cancer Registries and the Nordic Society of Pediatric Hematology and Oncology

PURPOSE

To assess the risk of subsequent malignant neoplasms among Hodgkin's disease patients diagnosed before 20 years of age in the five Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden).

PATIENTS AND METHODS

There were 1,641 Hodgkin's disease patients identified through the national cancer registries since the 1940s or 1950s. The patients were monitored for 17,000 person-years until the end of 1991. Expected figures were derived from the age-specific incidence rates in each country and standardized incidence ratios (SIR) were calculated.

RESULTS

A total of 62 subsequent neoplasms were diagnosed (SIR, 7.7; 95% confidence interval [CI], 5.9 to 9.9). The overall cumulative risk of subsequent neoplasms was 1.9% at the 10-year follow-up point, 6.9% at 20 years, and 18% at 30 years. There were 26 subsequent neoplasms among males (SIR, 6.5; 95% CI, 4.3 to 9.6) and 36 among females (SIR, 8.9; 95% CI, 6.2 to 12), of which 16 were breast cancers (SIR, 17; 95% CI, 9.9 to 28). High risks were seen for thyroid cancer (SIR, 33; 95% CI, 15 to 62), for secondary leukemia (SIR, 17; 95% CI, 6.9 to 35), and for non-Hodgkin's lymphoma (SIR, 15; 95% CI, 4.9 to 35). The relative risk increased from 3.3 (95% CI, 1.2 to 7.1) for Hodgkin's disease patients diagnosed in the 1940s and 1950s to 15 (95% CI, 7.4 to 27) in the 1980s. The highest risk of secondary leukemia (SIR, 68; 95% CI, 18 to 174) was seen among those diagnosed with Hodgkin's disease in the 1980s.

CONCLUSION

Patients who survive Hodgkin's disease at a young age are at very high relative risk of subsequent malignant neoplasms throughout their lives. In particular, the high relative risk of breast cancer following Hodgkin's disease in the teenage years calls for enhanced activity for early diagnosis.

[Survival after childhood cancer in Denmark 1943-1987. A population-based study]

Survival from cancer in childhood and adolescence was studied in 8312 children aged 0-19 years notified to the Danish Cancer Registry during 1947-1987. During the first period (1943-1972), five-year survival rates from all malignant neoplasms increased from 23% (1943-1952) to 33% (1963-1972). The greatest improvement was seen during the period 1973-87 when five-year survival rates reached 64% (1983-1987). Between 1973-1977 and 1983-1987, five-year survival rates increased from 32% to 62% for leukaemia, from 40 to 70% for acute lymphoblastic leukaemia, from 35 to 54% for non-Hodgkin's lymphoma, from 50 to 66% for central nervous system neoplasms and from 25 to 49% for bone tumours. An improvement in five-year survival rates for Wilms' tumour was seen between 1960 (19%) and 1980 (81%). Up to 1972, the five-year survival rate from germ-cell neoplasms was approximately 40%; among patients diagnosed in 1973-1987, 76% survived for five years. Survival was similar for boys and girls during the early period, but was significantly higher for girls subsequently. A marked effect of age at diagnosis was seen in the early registration period where survival rates for the age group 0-9 years was substantially lower compared to the age group 10-19 years. This inequality persisted only for children less than two years of age in the later period.

[Snowboarding accidents 1991 to 1994--an analysis]

437 snowboard injuries were taken under surveilance in the years 1991 till 1994. The average age was 21.5 years. 422 (97%) injuries were caused by a crash, only 15 (3%) by a collision. 178 patients (41%) needed only one single office visit, 259 patients (59%) had to undergo longer outpatient treatment (mean 27d). Only 34 patients (8%) needed inpatient treatment with an average stay of 4.44 days. 127 patients (29%) were on sick leave for several days (mean 20.57d). The most common diagnosis was a distortion 183 (38%), followed by fractures 148 (31%) and contusions 98 (21%). The upper extremities were the predominant injury site in 51% (245) with no prevalence of left or right. The lower extremities were injured in 34% (163) with a prevalence of the left leg 2/3. Head, spine, chest and abdomen were injured in 15% (69). The typical snowboarders injury however is an injury of the wrist (182/27%). Here of 71 (39%) were fractures of the distal radius. The knee joint being the second most common injury sight in 109 (16%) cases, mainly with sprains (63p/60%), seldomly with meniscal tears and/or ligament ruptures (10p/10%) and rarely fractures (3p / 3%). The fixation of both legs during snowboarding seems to be protective against complex knee joint injuries. Other regions were injured in less than 10%.

Unreamed intramedullary nailing of femoral fractures

Seventy-five patients with 81 femoral shaft fractures were treated with unreamed antegrade intramedullary nailing using a titanium alloy implant (AIM femoral nail, ACE Medical) with static interlocking. There were 73 closed fractures and 8 open fractures. Six patients had bilateral femoral shaft fractures. In two cases there was an ipsilateral fracture of the femoral neck, two patients had an ipsilateral intertrochanteric fracture, in one case there was a concomitant subtrochanteric fracture, and four patients had sustained an ipsilateral fracture of the acetabulum in addition to their femoral shaft fractures. In 43 cases (53%) the fracture of the femoral shaft was a comminuted type fracture. Thirty-nine patients (52%) had suffered multiple injuries; the mean Injury Severity Score was 41.2. Sixty-nine fractures were stabilized primarily within 8 hours after admission and 12 fractures were treated secondarily, in a mean of 5.8 days after injury. Closed intramedullary nailing was performed in 73 femora and open nailing with cerclage wiring was done in 8. All 81 nails were implanted unreamed and static was used in every case. The diameters of the nails used were 9 mm (n = 68) and 10 mm (n = 13). Proximal interlocking was distally directed in 76 cases and proximally directed in 5 cases. Two patients died of severe head injuries and one patient died of multiple organ failure. The infection rate was 0%, and uneventful consolidation of the fractures was seen in all cases within a mean of 3.8 months. Neither in the case of nails nor in the case of interlocking bolts did an implant failure occur.

[Donor site morbidity following radial forearm flap]

The results concerning morbidity of the fasciocutaneous radial forearm flap donor site of 20 patients are presented. The review was carried out with an average time of 4.4 years after raising the flaps, ranging from ten months to eleven years. Range of motion of the wrist joint was limited in extension in two patients with 15 degrees and in one patient with 30 degrees. Pinch and grip strength was found normal in 13 patients and was limited in five cases to 88% of the strength of the opposite limb. Dysesthetic areas were found in three patients on the radial border of the donor site and reduced sensation of the radial nerve was present in four patients.

Trends in survival after childhood cancer in Denmark, 1943-87: a population-based study

Survival from cancer in childhood and adolescence was studied in a population-based series of 8312 cases in children aged 0-19 years notified to the Danish Cancer Registry during 1943-87. During the first period (1943-72), 5-year survival rates from all malignant neoplasms increased from 23% (1943-52) to 33% (1963-72). The greatest improvement was seen during the period 1973-87 when 5-year survival rates reached 64% (1983-87). Between 1973-77 and 1983-87, 5-year survival rates increased from 32% to 62% for leukaemia, from 40% to 70% for acute lymphoblastic leukaemia, from 35% to 54% for non-Hodgkin's lymphoma, from 50% to 66% for central nervous system neoplasms and from 25% to 49% for bone tumours. An improvement in 5-year survival rates from Wilms' tumour was seen between 1960 (19%) and 1980 (81%). Up to 1972, the 5-year survival rate from germ-cell neoplasms was approximately 40%; among patients diagnosed in 1983-87, 76% survived for 5-years. Annual lethality decreased by 2.5% for all malignant neoplasms in 1943-72 and by 4.4% in 1972-87. Lethality was similar for boys and girls during the period 1943-72, but was significantly lower for girls subsequently. A marked effect of age at diagnosis was seen in the early registration period, where lethality rate for the age group 0-9 years was substantially higher compared with that in the age group 10-19 years. This inequality persisted only for children less than 2 years of age at the time of diagnosis in the later period.

[Acute lymphoblastic leukemia in children. A retrospective study: 1970-1991]

From January 1970 through December 1991, 94 girls and 130 boys with a median age of 4.8 years were diagnosed with non-B cell acute lymphoblastic leukaemia (ALL) at the University Hospital, Rigshospitalet. Intensive risk-group adapted therapy based on age and white-cell count (WBC) at diagnosis, the presence of a mediastinal mass, central nervous system (CNS) or testicular leukaemia, T-cell disease, and certain cytogenetic translocations have been used since July 1981. Ninety-seven percent of all patients achieved complete remission (all patients diagnosed since July 1986). Ninety patients relapsed, all within five years from diagnosis: 59 in bone-marrow (BM), 20 in CNS (no BM-involvement), nine in testes (all isolated), one in the eye, and one in a lymph node. The five-year event-free survival increased from 0.20 to 0.72 from the first to the last five-year period (p < 0.0001). Age and WBC at diagnosis were of prognostic significance during the period 1970-1981, but not during the last 10-year period, when risk-adapted therapy was applied. Following a relapse, patients with an isolated testicular focus had the best five-year survival as compared to patients with CNS- and/or BM-involvement (1.00 vs 0.19; p = 0.003). Patients relapsing following cessation of therapy had a better prognosis than did patients relapsing on therapy (five-year survival 0.58 vs 0.17; p = 0.002). Identification of new risk factors, more individualized therapy and monitoring of minimal residual disease is expected to have increasing influence on the management of children with ALL.

Normal final height after treatment for acute lymphoblastic leukemia without irradiation

In order to evaluate the influence of chemotherapy on linear growth, 28 children treated for acute lymphoblastic leukemia without irradiation were evaluated before, during and after the end of therapy. Median age at diagnosis was 4.4 years (range 2.2-12.7 years) and treatment was discontinued after a median period of 3.1 years (3.0-5.2 years). We observed a significant decrease in height SDS (p = 0.006) from diagnosis to the end of chemotherapy, followed by catch-up in height SDS from the end of chemotherapy to final observation. Catch-up growth took place mainly within the first 2 years after cessation of therapy. In 22 patients final height was reached. Final height was normal (median height SDS -0.035) and even significantly higher than mid-parental height SDS (p = 0.012). In those patients who attained adult stature, the sitting height to standing height ratio was also normal. In conclusion, in children treated for acute lymphoblastic leukemia, chemotherapy exerted a negative influence on growth, but catch-up occurred within 2 years after cessation of therapy, resulting in normal final height and body proportions.

[Second cancer. Risk of a second malignant neoplasm in persons with cancer in childhood and adolescence]

Cancer treatments in early life have in previous studies been associated in with high risks of developing a second malignant neoplasm. This study reports on the relative and attributable risks of second malignant neoplasms among 30,880 people under the age of 20, who had been identified in the files of any of the five Nordic cancer registers, 1943-1987. Overall, 247 cases of second malignant neoplasms were observed in 238 patients, yielding a relative risk for cancer of 3.6 (95% confidence interval 3.1-4.1). The risk changed significantly from 2.6 in people first diagnosed during the 1940s and 1950s to 6.9 among cohort members included in the late 1970s and 1980s. Highest levels of the relative risk were seen during the ten years immediately after first malignant diagnosis. The incidence of second malignant neoplasms attributable to the first cancer and associated treatments, however, showed a consistent rise throughout the 45 years of follow up. It was concluded that the estimated risks for second malignant neoplasms were significantly lower than those found in most large hospital based studies but compatible with the results from a similar population based study in the United Kingdom. Extent of risk and cancer pattern were similar among the Nordic countries and are believed to be representative for a large part of the European population.