Eight-plate epiphysiodesis

Aims

Guided growth using eight-plates is commonly used for correction of angular limb deformities in growing children. The principle is of tethering at the physeal periphery while enabling growth in the rest of the physis. The method is also applied for epiphysiodesis to correct limb-length discrepancy (LLD). Concerns have been raised regarding the potential of this method to create an epiphyseal deformity. However, this has not been investigated. The purpose of this study was to detect and quantify the occurrence of deformities in the proximal tibial epiphysis following treatment with eight-plates.

Patients and Methods

A retrospective study was performed including 42 children at a mean age of 10.8 years (3.7 to 15.7) undergoing eight-plate insertion in the proximal tibia for correction of coronal plane deformities or LLD between 2007 and 2015. A total of 64 plates were inserted; 48 plates (34 patients) were inserted to correct angular deformities and 16 plates (8 patients) for LLD. Medical records, Picture Archive and Communication System images, and conventional radiographs were reviewed. Measurements included interscrew angle, lateral and medial plateau slope angles measured between the plateau surface and the line between the ends of the physis, and tibial plateau roof angle defined as 180° minus the sum of both plateau angles. Measurements were compared between radiographs performed adjacent to surgery and those at latest follow-up, and between operated and non-operated plateaus. Statistical analysis was performed using BMDP Statistical Software.

Results

Slope angle increased in 31 (49.2%) of operated epiphyses by a mean of 5° (1° to 23°) compared with 29 (31.9%) in non-operated epiphyses (p = 0.043). Roof angle decreased in 29 (46.0%) of operated tibias and in 25 (27.5%) of non-operated ones by a mean of 5° (1° to 18°) (p = 0.028). Slope angle change frequency was similar in patients with LLD, varus and valgus correction (p = 0.37) but roof angle changes were slightly more frequent in LLD (p = 0.059) and correlated with the change in inter screw angles (r = 0.74, p = 0.001).

Conclusion

The use of eight-plates in the proximal tibia for deformity correction and limb-length equalization causes a change in the bony morphology of the tibial plateau in a significant number of patients and the effect is more pronounced in the correction of LLD. Cite this article: Bone Joint J 2018;100-B:1112–16.

A novel mutation in the GAN gene causes an intermediate form of giant axonal neuropathy in an Arab-Israeli family

Giant axonal neuropathy is a severe autosomal recessive neurodegenerative disorder of childhood that affects both the peripheral and central nervous systems. It is caused by mutations in the GAN gene linked to chromosome 16q24.1 At least 45 distinct disease-causing mutations have been identified throughout the gene in families of various ethnic origins, with different symptomatologies and different clinical courses. To date, no characteristic mutation or phenotype-genotype correlation has been established. We describe a novel missense mutation in four siblings born to consanguineous parents of Arab original with clinical and molecular features compatible with giant axonal neuropathy. The phenotype was characterized by a predominant motor and sensory peripheral neuropathies and severe skeletal deformities.

Treatment of Achilles tendon calcinosis in juvenile dermatomyositis with external ilizarov fixator

Calcinosis is a devastating complication of juvenile dermatomyositis and a challenging therapeutic problem. We report the use of an external Ilizarov fixator for the treatment of Achilles tendon calcinosis causing severe disability in a young girl with juvenile dermatomyositis.

Prenatal ultrasound diagnosis of club foot: outcome and recommendations for counselling and follow-up

Club foot was diagnosed by ultrasonography in 91 feet (52 fetuses) at a mean gestational age of 22.1 weeks (14 to 35.6). Outcome was obtained by chart review in 26 women or telephone interview in 26. Feet were classified as normal, positional deformity, isolated club foot or complex club foot. At initial diagnosis, 69 feet (40 fetuses) were classified as isolated club foot and 22 feet (12 fetuses) as complex club foot. The diagnosis was changed after follow-up ultrasound scan in 13 fetuses (25%), and the final ultrasound diagnosis was normal in one fetus, isolated club foot in 31 fetuses, and complex club foot in 20 fetuses. At birth, club foot was found in 79 feet in 43 infants for a positive predictive value of 83%. Accuracy of the specific diagnosis of isolated club foot or complex club foot was lower; 63% at the initial ultrasound scan and 73% at the final scan. The difference in diagnostic accuracy between isolated and complex club foot was not statistically significant. In no case was postnatal complex club foot undiagnosed on fetal ultrasound and all inaccuracies were overdiagnoses. Karyotyping was performed in 25 cases. Abnormalities were noted in three fetuses, all with complex club foot and with additional findings on ultrasound.

Immobilisation of forearm fractures in children

Redisplacement of unstable forearm fractures in plaster is common and may be the result of a number of factors. Little attention has been paid to the influence of immobilisation with the elbow extended versus flexed. We prospectively treated 111 consecutive children from two centres with closed forearm fractures by closed reduction and casting with the elbow either extended (60) in China or flexed (51) in Israel. We compared the outcome of the two groups. There was no statistically significant difference in the distribution of the age of the patients, the site of fracture or the amount of angulation and displacement between the groups. During the first two weeks after reduction, redisplacement occurred in no child immobilised with the elbow extended and nine of 51 children (17.6%) immobilised with the elbow flexed. Immobilisation of unstable forearm fractures with the elbow extended appears to be a safe and effective method of maintaining reduction.

Monitoring of the sciatic nerve during hamstring lengthening by evoked EMG

Traction injury to the sciatic nerve can occur during hamstring lengthening. The aim of this study was to monitor the influence of hamstring lengthening on conduction in the sciatic nerve using evoked electromyography (EMG).

Ten children with spastic cerebral palsy underwent bilateral distal hamstring lengthening. Before lengthening, the evoked potential was recorded with the patient prone. During lengthening, it was recorded with the knee flexed to 90°, 60° and 30°, and at the end of lengthening with the hip and knee extended.

In all patients, the amplitude of the evoked EMG gradually decreased with increasing lengthening. The mean decrease with the knee flexed to 60° was 34% (10 to 77), and to 30°, 86% (52 to 98) compared with the pre-lengthening amplitude. On hip extension at the end of the lengthening procedure, the EMG returned to the pre-lengthening level.

Monitoring of the evoked EMG potential of the sciatic nerve during and after hamstring lengthening, may be helpful in preventing traction injury.

Bone mineral density and metabolism in familial dysautonomia

Familial dysautonomia (FD) patients suffer from multiple fractures and have reduced bone pain, which defers the diagnosis. The pathogenesis of bone fragility in FD is unknown. This study aimed to characterize bone mineral metabolism and density in FD. Seventy-nine FD patients aged 8 months to 48 years (mean age 13.9 +/- 10.4 years, median 12.3) were studied. Clinical data included weight, height, bone age, weekly physical activity and history of fractures. Bone mineral density (BMD) of the lumbar spine (n = 43), femoral neck (n = 26), total hip (n = 22) and whole body (n = 15) were determined by dual-energy X-ray absorptiometry. Serum 25-hydroxyvitamin D3, osteocalcin, bone alkaline phosphatase (B-ALP), parathyroid hormone and urinary N-telopeptide cross-linked type 1 collagen (NTx) were determined in 68 patients and age- and sex-matched controls. Forty-two of 79 patients (53%) sustained 75 fractures. Twenty-four of 43 patients had a spine Z-score < -2.0, and 13 of 26 had a femoral neck Z-score < -2.0. Mean femoral neck BMD Z-score was lower in patients with fractures compared with those without (-2.5 +/- 0.9 vs -1.5 +/- 1.0, p = 0.01). Mean body mass index (BMI) was 16 kg/m2 in prepubertal patients and 18.4 kg/m2 in postpubertal patients. Bone age was significantly lower than chronological age (75.5 vs 99.3 months in prepubertal patients, p < 0.001; 151 vs 174 in postpubertal patients, p < 0.05). NTx and osteocalcin levels were higher in FD patients compared with controls (400 +/- 338 vs 303 +/- 308, BCE/mM creatinine p < 0.02; 90 +/- 59.5 vs 61.8 +/- 36.9 ng/ml, p < 0.001, respectively). B-ALP was lower in FD patients compared with controls (44.66 +/- 21.8 vs 55.36 +/- 36.6 ng/ml, p < 0.04). Mean spine Z-score was significantly lower in physically inactive compared with active patients (-3.00 +/- 1.70 vs -1.77 +/- 1.3, respectively, p = 0.05). We conclude that fractures in FD patients are associated with reduced BMD. FD patients have increased NTx and osteocalcin. Contributing factors include reduced BMI, failure to thrive and reduced physical activity. Preventive therapy and early diagnosis are essential.

Congenital insensitivity to pain

We reviewed 13 patients with congenital insensitivity to pain. A quantitative sweat test was carried out in five and an intradermal histamine test in ten. DNA examination showed specific mutations in four patients. There were three clinical presentations: type A, in which multiple infections occurred (five patients); type B, with fractures, growth disturbances and avascular necrosis (three patients); and type C, with Charcot arthropathies and joint dislocations, as well as fractures and infections (five patients, four with mental retardation).

Patient education, shoeware and periods of non-weight-bearing are important in the prevention and early treatment of decubitus ulcers. The differentiation between fractures and infections should be based on aspiration and cultures to prevent unnecessary surgery. Established infections should be treated by wide surgical debridement. Deformities can be managed by corrective osteotomies, and shortening by shoe raises or epiphysiodesis. Joint dislocations are best treated conservatively.

Congenital insensitivity to pain. Orthopaedic manifestations

We reviewed 13 patients with congenital insensitivity to pain. A quantitative sweat test was carried out in five and an intradermal histamine test in ten. DNA examination showed specific mutations in four patients. There were three clinical presentations: type A, in which multiple infections occurred (five patients); type B, with fractures, growth disturbances and avascular necrosis (three patients); and type C, with Charcot arthropathies and joint dislocations, as well as fractures and infections (five patients, four with mental retardation). Patient education, shoeware and periods of non-weight-bearing are important in the prevention and early treatment of decubitus ulcers. The differentiation between fractures and infections should be based on aspiration and cultures to prevent unnecessary surgery. Established infections should be treated by wide surgical debridement. Deformities can be managed by corrective osteotomies, and shortening by shoe raises or epiphysiodesis. Joint dislocations are best treated conservatively.

Musculoskeletal deformities in Behr syndrome

SUMMARY

Seventeen children with Behr syndrome were investigated, focusing on the musculoskeletal deformities and long-term outcome. Behr syndrome is characterized by optic atrophy beginning in early childhood associated with ataxia, spasticity, mental retardation, and posterior column sensory loss. The ataxia, spasticity, and muscle contractures, mainly of the hip adductors, hamstrings, and soleus, are progressive and become more prominent in the second decade. In 70% of the patients, contractures developed in the lower limbs, requiring surgery mainly for the Achilles tendon, hamstrings, and adductor longus. At last follow-up at an average age of 21.7 years (range, 8-31 years), 13 of the patients are housebound walkers, 2 are nonfunctional walkers, and 2 are nonwalkers.

Orthopaedic manifestations of familial dysautonomia. A review of one hundred and thirty-six patients

BACKGROUND

Familial dysautonomia is a hereditary multisystemic disease primarily affecting people of Ashkenazi Jewish descent. Musculoskeletal problems are related to gait disorders, spinal deformities, foot deformities, fractures, and arthropathies.

METHODS

The charts and radiographs of 136 patients who ranged in age from three months to forty-six years (mean, sixteen years) were reviewed. Sixty-four patients were available for follow-up examination.

RESULTS

Spinal deformity was the most common orthopaedic problem and was diagnosed in seventy-eight patients starting at the age of four years, with a prevalence of 86 percent (forty-eight of fifty-six) by the age of fifteen years. Forty-one (53 percent) of the seventy-eight patients had scoliosis only, thirty-four (44 percent) had kyphoscoliosis, and three (4 percent) had kyphosis only. Bracing was accompanied by emotional, pulmonary, and skin problems, leading to a high rate of noncompliance and progression of the curve. Twenty-four patients had an operation at a mean age of thirteen years (range, five to eighteen years): twenty patients had posterior spinal arthrodesis, and four had combined anterior and posterior arthrodesis. Fifteen patients had a total of nineteen complications, of which seven were systemic and twelve were related to the spinal fixation. Eight patients had revision surgery. At the time of the surgery, scoliosis was corrected from a mean of 55 degrees to a mean of 35 degrees and kyphosis was corrected from a mean of 69 degrees to a mean of 61 degrees. After a mean duration of follow-up of sixty-five months, scoliosis measured 49 degrees (range, 18 to 62 degrees) and kyphosis measured 67 degrees (range, 30 to 115 degrees). Postoperative progression of the deformity was caused by failure of the instrumentation or progression in unfused segments. Walking was delayed in 72 percent (ninety-four) of the 130 patients who were of walking age. All sixty-four of the patients who were examined had an ataxic gait. Foot deformities were found in sixteen patients, six of whom were treated surgically. Two patients had Charcot joints. Fifty-five patients sustained at least one fracture before skeletal maturity, with a mean of 1.5 fractures per patient. All but one of the fractures was treated nonoperatively, and fracture-healing was often accompanied by profuse callus formation.

CONCLUSIONS

Spinal deformity is common in patients with familial dysautonomia. Bracing is of questionable benefit, and surgical intervention should be considered once curve progression is well documented. Arthrodesis should be extended as far proximally as possible to prevent junctional kyphosis. Swelling and warmth in a limb should raise suspicion of an undiagnosed fracture.

Is diagnostic testicular fine needle aspiration necessary in azoospermic men before sperm aspiration/extraction for intracytoplasmic sperm injection cycles?

PURPOSE

To determine whether diagnostic testicular fine needle aspiration (TEFNA) sampling needs to be performed in azoospermic men prior to obtaining testicular sperm cells for IVF-ICSI procedures.

METHODS

Ten azoospermic patients underwent TEFNA in 1993-1996. During 1997, all patients underwent testicular sperm aspiration (TESA) and/or testicular sperm extraction (TESE) to retrieve spermatozoa for IVF-ICSI cycles. The results of the two procedures performed in two separate hospitals were compared.

RESULTS

Diagnostic TEFNA revealed spermatozoa in five patients; identical results in four were found during IVF-ICSI cycles. In three patients, only Sertoli cells were found on TEFNA, in two of them TESA/TESE showed identical results, and in one, two spermatozoa were detected by Cyto-SEM. In the remaining two patients, spermatids or spermatocytes were found on both procedures.

CONCLUSIONS

There was a very good correlation between the diagnostic and therapeutic procedures. We suggest that in azoospermic patients, diagnostic TEFNA is valuable in order to avoid unnecessary controlled ovarian hyperstimulation in the female partner for IVF. In patients in whom spermatozoa are detected, cryopreservation may be performed for later IVF-ICSI cycles.

[Follicle-stimulating hormone in azoospermia in prediction of spermatogenic patterns]

Follicle-stimulating hormone (FSH) is considered to be the most important plasma hormone correlated with spermatogenesis. Elevated FSH plasma levels were shown to be associated with complete damage to testicular seminiferous tubule germinal epithelium. Recently, there have been conflicting reports with regard to the value of FSH plasma levels in predicting seminiferous tubule histology in the azoospermic patient and hence, as a guide for therapy in assisted reproduction using testicular sperm retrieval. The aim of this study was to evaluate whether FSH plasma levels can predict spermatogenic pattern in the testes of the azoospermic infertile patient. 69 infertile men with non-obstructive azoospermia and 18 with very severe oligospermia were studied. In all, plasma levels of testosterone, free testosterone, prolactin, luteinizing hormone and follicle-stimulating hormone were measured by enzyme immunoassay. In the azoospermic patients the seminiferous tubule spermatogenic pattern was determined in testicular aspirates obtained by multiple fine needle aspiration and categorized according to the most mature spermatogenic cell type in the aspirates: Sertoli cells only, spermatogenic maturation arrest or full spermatogenesis. There were no significant differences in plasma levels of any hormone measured except in very severely oligospermic and azoospermic patients. Both normal and elevated levels were detected in all, regardless of seminiferous tubule cytological pattern or plasma FSH in azoospermic patients. It is concluded that plasma levels of FSH can not be used as a predictive parameter, neither for the presence of spermatozoa nor for any other seminiferous tubule cytological pattern in azoospermic infertile men. They cannot serve as guides for selection of azoospermic men for trials of testicular sperm retrieval in assisted reproduction.

Compression of the esophagus by the spine and the aorta in untreated scoliosis

An adult patient with severe scoliosis secondary to familial dysautonomia developed dysphagia and recurrent aspirations. Various imaging studies showed a mechanical obstruction of the esophagus due to compression between the spine and the aorta. The patient underwent a gastrostomy and fundoplication, with a significant decrease in symptoms. The case demonstrates one of the possible long-term consequences of untreated scoliosis.

Ultrasonography of the hip in developmental hip dysplasia

Ultrasonography of the hip was performed sequentially by two different examiners in 75 infants. The ultrasound strips were reviewed twice by three paediatric orthopaedic surgeons and classified by the Graf method. The intraobserver and interobserver agreement between the interpretations was analysed using simple and weighted kappa coefficients calculated for agreement on the Graf classification and for grouping as normal (types 1A to 2A), and abnormal requiring treatment (types 2B to 4). When examining the same ultrasound strip, intraobserver agreement for the Graf classification was substantial (mean kappa 0.61), but interobserver agreement was only moderate (kappa 0.50). For the grouping into normal and abnormal, the mean kappa value for intraobserver agreement was 0.67 and for interobserver agreement 0.57. Because of the significant differences in agreement between normal and abnormal hips, we analysed a subgroup of those with at least one abnormal interpretation. Intraobserver agreement within this subgroup showed moderate reliability (kappa 0.41), but interobserver agreement was only fair (kappa 0.28). Interpretations of two different strips performed sequentially showed significantly lower agreement with an intraobserver kappa value of 0.29 and an interobserver value of 0.28. In the subgroup with at least one abnormal reading, the intraobserver kappa was 0.09 and the interobserver 0.1. Our findings suggest that both the technique of performing ultrasonography and the interpretation of the image may influence the result.

Ultrasonography of the hip in developmental hip dysplasia

Ultrasonography of the hip was performed sequentially by two different examiners in 75 infants. The ultrasound strips were reviewed twice by three paediatric orthopaedic surgeons and classified by the Graf method. The intraobserver and interobserver agreement between the interpretations was analysed using simple and weighted kappa coefficients calculated for agreement on the Graf classification and for grouping as normal (types 1A to 2A), and abnormal requiring treatment (types 2B to 4).

When examining the same ultrasound strip, intraobserver agreement for the Graf classification was substantial (mean kappa 0.61), but interobserver agreement was only moderate (kappa 0.50).

For the grouping into normal and abnormal, the mean kappa value for intraobserver agreement was 0.67 and for interobserver agreement 0.57. Because of the significant differences in agreement between normal and abnormal hips, we analysed a subgroup of those with at least one abnormal interpretation. Intraobserver agreement within this subgroup showed moderate reliability (kappa 0.41), but interobserver agreement was only fair (kappa 0.28).

Interpretations of two different strips performed sequentially showed significantly lower agreement with an intraobserver kappa value of 0.29 and an interobserver value of 0.28. In the subgroup with at least one abnormal reading, the intraobserver kappa was 0.09 and the interobserver 0.1.

Our findings suggest that both the technique of performing ultrasonography and the interpretation of the image may influence the result.

[Does testicular volume reflect spermatogenic pattern in men with azoospermia?]

The aim of this study was to determine whether testicular volume can serve to predict patterns of spermatogenesis in azoospermia. In 27 tests of azoospermic infertile men, cytological specimens from several sites from each testis were obtained by fine needle aspiration. Testes were classified according to the most mature spermatogenic cell type. Classifications were testes with spermatozoa, with arrested spermatogenic development, and with only Sertoli cells. Prior to fine needle aspiration the 3 dimensions of each testis were determined ultrasonically and its volume calculated. Mean testicular volume (+/- SD) was 7.71 (+/- 5.95) ml for testes with spermatozoa and 7.55 (+/- 2.35) and 7.31 (+/- 4.42) ml for testes with spermatogenic maturation arrest and with only Sertoli cells, respectively (differences not significant). It is concluded that testicular volume can not be used as a predictive parameter, neither for the presence of spermatozoa nor for the cytological pattern of the testes of azoospermic infertile men.

[Are testes in oligo/azoospermia homogenous or heterogenous?]

We determined whether a single testicular specimen is sufficient to represent qualitatively the spermatogenic process within the testes of azoospermic or severely oligospermic infertile men. In 191 testes of azoospermic patients and in 26 of those with severe oligospermia, fine needle aspirations at 3 different sites of each testis were performed. Aspirated material from each puncture was stained and in each smear all spermatogenic cells, as well as Sertoli cells, were identified. Testes were classified according to the most mature spermatogenic cell type present, or the presence of only Sertoli cells. The homogeneity of the testicular spermatogenic process was then evaluated. There was an overall intratesticular difference between aspirates in 14.1% of azoospermic testes and in 26.9% of severely oligospermic testes with regard to the most mature spermatogenic cell type. When spermatozoa were the most mature cell type, they were detected in all of the 3 aspirates in 71.4% of the testes. In 18.4% or 10.2% of this group of testes they were retrieved in only 1 or 2 of the aspirates, respectively. In testes in which spermatids or spermatocytes were the most mature spermatogenic stage, these cell types were detected in all 3 aspirates in only 36.4% and 68.0%, respectively. In azoospermic patients with full testicular spermatogenesis, the likelihood of retrieving spermatozoa from the testes was 84.3%, 92.7% and 100% in 1, 2 and 3 specimens, respectively. The following conclusions were drawn: There is a wide range of testicular heterogeneity in azoospermia or very severe oligospermia for diagnosing the testicular spermatogenic pattern. In azoospermia, specimens from several testicular sites are required. It is strongly recommended that no assisted fertilization be offered to azoospermic patients unless prior evaluation of the spermatogenic pattern in the seminiferous tubules is determined.

Traumatic myositis ossificans of the quadriceps in infants

Acute traumatic myositis ossifications is uncommon and usually occurs in adolescents and young adults after a significant direct blow to the affected muscle. It is extremely rare in infants, and we have been able to find only two other cases in the English literature. We present two cases of traumatic myositis ossificans in infants who, except for the use of diagnostic ultrasonography, would have been misdiagnosed as having osteomyelitis (Patient 1) and a possible malignancy (Patient 2).

External fixation or flexible intramedullary nailing for femoral shaft fractures in children. A prospective, randomised study

We report the outcome of 19 children aged 5.2 to 13.2 years with 20 fractures of the femoral shaft requiring surgery, who were randomly assigned to have external fixation (EF) or flexible intramedullary nailing (FIN) (10 fractures each). The duration of the operation averaged 56 minutes for the EF group with 1.4 minutes of fluoroscopy, compared with 74 minutes and 2.6 minutes, respectively, for the FIN group. The early postoperative course was similar, but the FIN [corrected] group showed much more callus formation. The time to full weight-bearing, full range of movement and return to school were all shorter in the FIN group. The FIN complications included one transitory foot drop and two cases of bursitis at an insertion site. In the EF group there was one refracture, one rotatory malunion requiring remanipulation and two pin-track infections. At an average follow-up of 14 months two patients in the EF group had mild pain, four had quadriceps wasting, one had leg-length discrepancy of over 1 cm, four had malalignment of over 5 degrees, and one had limited hip rotation. In the FIN group, one patient had mild pain and one had quadriceps wasting; there were no length discrepancies, malalignment or limitation of movement. Parents of the FIN group were more satisfied. We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft which require surgery, and reserve external fixation for open or severely comminuted fractures.

EXTERNAL FIXATION OR FLEXIBLE INTRAMEDULLARY NAILING FOR FEMORAL SHAFT FRACTURES IN CHILDREN

We report the outcome of 19 children aged 5.2 to 13.2 years with 20 fractures of the femoral shaft requiring surgery, who were randomly assigned to have external fixation (EF) or flexible intramedullary nailing (FIN) (10 fractures each). The duration of the operation averaged 56 minutes for the EF group with 1.4 minutes of fluoroscopy, compared with 74 minutes and 2.6 minutes, respectively, for the FIN group.

The early postoperative course was similar, but the EF group showed much more callus formation. The time to full weight-bearing, full range of movement and return to school were all shorter in the FIN group. The FIN complications included one transitory foot drop and two cases of bursitis at an insertion site. In the EF group there was one refracture, one rotatory malunion requiring remanipulation and two pin-track infections.

At an average follow-up of 14 months two patients in the EF group had mild pain, four had quadriceps wasting, one had leg-length discrepancy of over 1 cm, four had malalignment of over 5°, and one had limited hip rotation. In the FIN group, one patient had mild pain and one had quadriceps wasting; there were no length discrepancies, malalignment or limitation of movement. Parents of the FIN group were more satisfied.

We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft which require surgery, and reserve external fixation for open or severely comminuted fractures.

Eosinophilic granuloma of the spine

Twenty patients treated for eosinophilic granuloma of the spine were studied. Only 40% demonstrated the classical radiographic picture of vertebra plana. In 60% a lytic lesion of the vertebral body or the posterior elements was found. Seven patients underwent surgery; the indications were neurological involvement or failure of the biopsy to disclose the diagnosis. At an average follow-up period of 7 years, 17 patients are well and alive with no residual spinal pain, neurological compromise, recurrent disease, or extraskeletal involvement. Vertebral body collapse underwent some regeneration but did not regain full body height. In several patients this resulted in a local deformity. In patients with unifocal spinal eosinophilic granuloma, watchful observation with no treatment other than spinal support is warranted. In patients with neural involvement or multifocal lesions, a more active treatment, including surgery, may be indicated.

[Seminiferous tubule cytological pattern in infertile, azoospermic men in diagnosis and therapy]

We determined spermatogenic patterns of seminiferous tubules in azoospermic infertile men and evaluated the prevalence of bilateral testicular homogeneity. 185 azoospermic men underwent bilateral testicular fine-needle aspiration (TFNA) in which each testis was punctured at 3 different positions. Aspirated material was stained and classified according to the most mature spermatogenic cell type present or whether only Sertoli cells were present. 35.7% had spermatozoa in their testes, 36.2% had spermatogenic maturation arrest, and 28.1% had only Sertoli cells in their seminiferous tubules. In 15.6% of all patients, the diagnosis in 1 testis differed from that in the other. In only 73.2% of those with testicular spermatozoa was it bilateral. In the remaining 26.9%, only Sertoli cells, spermatocytes or spermatids were found as the most mature cell type in the other testis. The study definitely indicates that fertilization with retrieved testicular spermatozoa should not be offered to azoospermic patients without prior evaluation of the seminiferous tubuespermatogenic pattern in both testes.

Early innominate osteotomy as a treatment for avascular necrosis complicating developmental hip dysplasia

The clinical and radiographic outcomes of 25 patients with avascular necrosis (AVN) of the femoral head complicating developmental hip dysplasia (DDH) were analyzed. Seven patients (group A) had an innominate osteotomy 1-3 years after the ischemic insult. Eight patients (group B) had a pelvic osteotomy between 5 and 10 years after the insult, and 10 patients (group C) did not have a pelvic osteotomy. The minimum follow-up period was 10 years from the time of the ischemic insult. The hips in group A patients (early osteotomy) showed significantly better radiographic outcomes as assessed by a modified Severin grading. These patients also had less pain, fewer gait disturbances, and required fewer additional procedures for limb length discrepancy or greater trochanteric overgrowth.

[Relationship between spermatogenic maturation stages and male hormone levels]

The relationship between stages of the spermatogenic maturation process and male hormone levels was evaluated in 41 azoospermic, infertile men. Patients were categorized into groups according to the most mature spermatogenic cell type present in testicular aspirates: spermatocytes, spermatids or spermatozoa. High FSH and LH plasma levels were found in those with spermatocytes. Their hormone levels differed statistically (p < 0.005) from those in patients with maturation arrest at the spermatid stage, or those with spermatozoa in their testes. No statistically significant differences were found between the 3 groups with regard to plasma levels of testosterone, free testosterone and prolactin. However, there were positive correlations, higher for free testosterone than for testosterone, with stage of spermatogenic maturation.

The use of ultrasound in the diagnosis of atypical pathology in the unossified skeleton

Three cases are presented: a congenital dislocation of the patella, a congenital dislocation of the radial head, and an epiphysiolysis of the distal humerus. In all three cases the pathology involved unossified parts of the skeleton poorly demonstrated by plain radiographs. Ultrasonography proved useful in diagnosis and treatment of these cases.

The relationship between plasma levels of gonadotropins, androgens, and prolactin in azoospermic men with their testicular spermatogenic pattern

OBJECTIVE

To assess the relationship between plasma levels of gonadotropins, androgens, and PRL with testicular spermatogenic pattern.

DESIGN

Patient series.

SETTING

University affiliated medical center.

PATIENTS

One hundred twenty azoospermic infertile men.

INTERVENTIONS

Testicular fine needle aspirations and determination of plasma levels of FSH, LH, T, free T, and PRL.

MAIN OUTCOME MEASURES

Gonadotropins, androgens, and PRL plasma levels as a diagnostic criterion of testicular spermatogenic patterns.

RESULTS

No statistically significant differences were detected in plasma levels of LH, androgens, and PRL among patients with Sertoli cell only, spermatogenic arrest, or full spermatogenesis. Elevated plasma levels of FSH threefold above the upper normal limit preclude, with a probability of 95%, the existence of full testicular spermatogenesis, but are not valid for the diagnosis of either Sertoli cell only syndrome or spermatogenic arrest.

CONCLUSIONS

Luteinizing hormone, androgens, and PRL plasma levels are of no diagnostic value in predicting any specific spermatogenic pattern, and plasma FSH levels can not be used for diagnosing Sertoli cell only syndrome.

[Epididymal fine needle aspiration replacing vasography]

Epididymal fine needle aspirations (EFNA) were performed on 29 epididymides of 17 infertile, azoospermic men in whom testicular cytology revealed adequate spermatogenesis. Sonograms confirmed the presence of all the excretory male organs. EFNA was performed to diagnose and locate the site of genital tract occlusion. The presence of cuboidal epithelial cells in the aspirate was the sole indication that epididymal content was aspirated. In 10 (34%) of the 29 aspirates there were only cuboidal epithelial cells and no spermatozoa, indicating proximal occlusion in the rete testis, in the canaliculi efferents or in the most proximal segment of the epididymis itself. Occlusion in the distal segments of the epididymis or in the vas deferens was diagnosed in 13 epididymal aspirates (45%) which contained both cuboidal cells and spermatozoa. In 6 epididymides (21%) no conclusion could be reached because of failed aspirations. There are a variety of treatment modalities available for male genital tract obstruction, such as reconstructive surgery or IVF. The success rate of treatment is mainly dependent on the site of obstruction. Since vasography has its own limitations and hazards, diagnostic EFNA should be performed before treatment in men in whom genital obstruction is suspected.

Testicular fine needle aspiration as a diagnostic method

We believe testicular FNA is a reliable, simple, and accurate method for the assessment of testicular pathology and can replace the biopsy. Only when insufficient conclusions may be drawn from the cytologic smears obtained is open biopsy indicated.

Effect of chemotherapy on human growth plate

Histologic specimens of the distal femoral growth plates of 10 patients treated surgically for osteosarcoma were examined retrospectively. Eight of the patients received preoperative chemotherapy. None of the specimens showed complete growth arrest. The gross thickness of the plates was preserved. Columnar arrangement of the cells was minimally disrupted. The number of proliferative cells in each column was decreased, and the number of hypertrophic cells, was increased slightly. The metaphysis showed longitudinal trabeculations with a high chondroid content. Growth arrest lines were evidenced by transverse trabeculations with a high osteoid content. Our findings provide histologic support for previous clinical studies. Absence of complete growth arrest and evidence of a resumption of growth are relevant in planning limb salvage procedures in patients receiving pre- and postoperative chemotherapy for skeletal malignancy.

Hip flexion contracture in cerebral palsy. The association between clinical and radiologic measurement methods

Hip flexion contracture was examined in 51 spastic cerebral palsy patients by three clinical methods and two radiologic methods. An extremely low association was found between the clinical and radiologic methods with no particular method, clinical or radiologic, showing a higher association. The method of clinical examination should be chosen by convenience. Radiologic measurements by the methods used did not add useful information.

The grandmultipara: is she still a risk?

Grandmultiparity is reported to increase both maternal and perinatal mortality and morbidity. Unique religious and demographic factors in Jerusalem allowed us to analyze a population wherein parity could be dissociated from socioeconomic status. A total of 7785 mothers was studied, 889 (11.5%) of whom were grandmultiparas. Comparison of grandmultiparous mothers with all others revealed no increase in the incidence of hypertension, diabetes, uterine atonia, antenatal or postnatal hemorrhage, cesarean sections, stillbirth rate, or congenital malformations. The grandmultipara had significantly lower neonatal mortality and low birth weight rates and a significantly higher incidence of multiple births and trisomy 21 (p less than 0.01). These results strongly suggest that grandmultiparity in and of itself in a healthy, economically stable population afforded modern medical care is not a major risk factor and that previous reports primarily reflected social class factors and not parity per se.

Tuboovarian autoamputation and infertility

Asymptomatic or undiagnosed tuboovarian autoamputation in teenagers may have its impact on fertility later in life. Two cases are presented with infertility following unilateral adnexal autoamputation. The importance of awareness for possible subtorsion or torsion of adnexa in childhood and adolescence and its impact on fertility are discussed.

Classical sleep stages and the spectral content of the EEG signal

Polygraphic sleep recordings during 12 nights in 5 healthy volunteers were classified manually into waking and the various sleep stages. The smoothed power spectra of EEG signal segments defined as waking or one of the sleep stages were calculated via segmentation of the EEG signal, using the autoregressive model, and time-dependent fuzzy clustering. The spectra were derived from the prediction coefficients of the segments. The relative power in the delta frequency band was found to increase monotonically with increasing depth of sleep, together with a parallel decrease in the alpha relative power. In most cases alpha relative power had a small peak during REM sleep, and on average the relative power in the sigma frequency band during REM sleep was smaller than the beta relative power. The power spectra from subjects with no waking alpha differed from those of subjects with abundant waking alpha mostly in the relative spectral content of stages 1 and REM. The significance of these findings is discussed in relation to future standardisation of automatic analysis of sleep recordings.

Fuzzy clustering of EEG signal and vigilance performance

An automatic method for classification of EEG data, based upon segmentation of the signal using the autoregressive model and decision making in fuzzy environment, is described. The classification is applied to explore the relations between EEG states during waking, and vigilance performance studied through auditory choice reaction time. The average auditory choice reaction time measured during occurrences of "alpha" segments was significantly shorter than that measured during occurrences of "nonalpha" signal segments. A significant negative correlation was also found between the segments auditory choice reaction time and the segments spectral power in the alpha or beta frequency band.

Automatic scoring of polygraphic sleep recordings: midazolam in insomniacs

Midazolam in doses of 0.21-0.46 mg/kg was given to four insomniacs for 27 days, and to a fifth insomniac for an additional 124 days, to assess its short, intermediate, long-term and long-standing efficacy. Automatic analysis of the polygraphic sleep recordings was carried out employing real-time signal processing (based on linear prediction), and an off-line sequential fuzzy clustering. Total sleep length did not vary significantly during medication, whereas other efficacy parameters such as sleep onset latency, wake time after sleep onset and number of nightly awakenings decreased significantly throughout the period of active medication. In one patient, midazolam was still effective after 151 days of administration. The ultrashort action (probably 3-4 h) of midazolam could be demonstrated by the distribution of the efficacy parameters, dividing the night into 2-h periods, by the unchanged total sleep length during medication compared with baseline and by the lack of any subjective clinical symptoms of hangover. The quantitative analysis of the signals showed that, although a decrease in the total amount of slow-wave sleep during long-term medication and withdrawal was detected, the total relative power in the delta band increased during drug administration. This was interpreted as redistribution of the delta activity during active medication. A lengthening of REM sleep was found during active medication probably attributable to intranight rebound. This was not followed by any clinical symptom of clinical REM rebound.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in the magnesium content of tissues following myocardial damage in rats

The magnesium content of blood, heart and striated muscle, liver, spleen, kidney and bone was determined in rats, 15, 30 and 60 minutes, 6 and 24 hours after isoprenaline induced myocardial damage. The magnesium concentration increased significantly in the serum (but not in the red cells) in the first three groups of animals, while the magnesium concentration of heart muscle fell in all groups. There was no evidence of magnesium flux in the other tissues.

Computerized analysis of sleep recordings applied to drug evaluation: midazolam in normal subjects

Computerized analysis of polygraphic sleep recordings was carried out for the evaluation of midazolam, a benzodiazepine hypnotic. The analysis was carried out in real time on a small laboratory computer, and the output included the hypnogram and relative power profiles for the main electroencephalogram activities. Analysis showed a slight "intranight rapid eye movement rebound" during medication and reduction of sleep stage IV after withdrawal. The relative power of the delta frequency band did not change during medication or withdrawal.