Rectocele: pathogenesis and surgical management

BACKGROUND

Rectocele is a common finding in patients with intractable evacuatory disorders. Although much rectocele surgery is conducted by gynecologists en passant with other forms of vaginal surgery, many reports lack appreciation of the importance of coincident anorectal symptoms, and do not report functional and clinical outcome data. The pathogenesis of rectocele is still controversial, as is the embryological and anatomical importance of the rectovaginal septum as well as recognizable defects in its integrity and its relevance in formal repair when rectocele is operated upon as the principal condition in patients with intractable evacuatory difficulty.

DISCUSSION

The investigation and surgical management of rectocele is controversial given the relatively small numbers of operated patients in any single specialist unit and the relative lack of prospective data concerning functional outcome in operated cases. The imaging of rectocele patients is currently in a state of change, and the newer diagnostic modalities including dynamic magnetic resonance imaging frequently display a multiplicity of pelvic floor disorders. When surgery is indicated, coloproctologists most commonly utilize an endorectal defect-specific repair, but there are few controlled randomized data regarding outcome and response criteria of specific symptoms with particular surgical approaches. A Medline-based literature search was conducted for this review to assess the clinical results of defect-specific rectocele repairs using the endorectal, transvaginal, transperineal, or combined approaches. Only the studies are included that report both pre- and postoperative symptoms including constipation, evacuatory difficulty, pelvic pain, the impression of a pelvic mass, fecal incontinence, dyspareunia or the need for assisted digitation to aid defecation.

CONCLUSION

The history of rectocele repair, its clinical and diagnostic features and the advantages, disadvantages and indications for the different surgical techniques are presented in this review. Suggested diagnostic and surgical therapeutic algorithms for management have been included. It is recommended that a multicenter controlled randomized trial comparing surgical approaches for symptomatic evacuatory dysfunction where rectocele is the principal abnormality should be conducted.

A phase I study of two dosing schedules of volasertib (BI 6727), an intravenous polo-like kinase inhibitor, in patients with advanced solid malignancies

BACKGROUND

Polo-like kinase 1 (Plk1) has an important role in mitosis. Volasertib (BI 6727), a potent and selective cell cycle kinase inhibitor, induces mitotic arrest and apoptosis by targeting Plk; this phase I study sought to determine its maximum tolerated dose (MTD) in Asian patients with advanced solid tumours.

METHODS

Patients were enrolled simultaneously into two 3-week schedules of volasertib: a 2-h infusion on day 1 (schedule A) or days 1 and 8 (schedule B). Dose escalation followed a 3+3 design. The MTD was determined based on dose-limiting toxicities (DLT) in the first treatment course.

RESULTS

Among 59 treated patients, the most common first course DLTs were reversible thrombocytopenia, neutropenia and febrile neutropenia; MTDs were 300 mg for schedule A and 150 mg for schedule B. Volasertib exhibited multi-exponential pharmacokinetics (PK), a long terminal half-life of ∼135 h, a large volume of distribution (>3000 l), and a moderate clearance. Partial responses were observed in two pre-treated patients (ureteral cancer; melanoma). Volasertib was generally well tolerated, with an adverse event profile consistent with its antimitotic mode of action and a favourable PK profile.

CONCLUSIONS

These data support further development of volasertib and a harmonised dosing for Asian and Caucasian patients.

Developmental changes in the retrorectal region of the human fetus

A morphological study concerning the development and arrangement of the connective tissue in the retrorectal region was performed by investigating 300-700 micron thick sections through fetal pelves, plastinated with the epoxy resin E 12 and cut with a diamond wire-saw. In 9-20-week old fetuses several developmental processes take place simultaneously in the retrorectal region: In the 9-week old fetus there is a marked incongruity between the curvature of the rectal wall and that of the caudal elements of the vertebral column. However, by the 20th week this incongruity has disappeared and the curvatures of the two structures parallel each other. During this developmental process, the position of the rectum in relation to the caudal parts of the vertebral column is changed. Due to the changing position of the rectum, alterations of the connective tissue are found especially in the precoccygeal portion of the retrorectal region. In the mesenchyme of 9-week old fetuses a differentiation of the retrorectal space into compartments can already be seen. With increasing age of the fetuses, three different compartments can be distinguished between the rectum and the ventral surface of the sacrum and coccyx. By the 20th week of human development fasciae can be identified within the connective tissue. In comparison to the various fasciae that have been described in the retrorectal region of the adult, only the pelvic parietal fascia is to be found in 20-week old fetuses. Fibres of this fascia traverse the retrorectal space and divide it into a presacral and a precoccygeal portion.

Topography of the pelvic autonomic nerves in human fetuses between 21-29 weeks of gestation

A topographical study concerning the autonomic nerves in the pelvis of human fetuses was performed by investigating 300-600 microns thick sections through fetal pelves, impregnated with the epoxy resin E 12 and cut with a diamond wire-saw. In addition the inferior hypogastric plexus of a 26-week old male fetus was dissected by lateral approach. In 21-29-week old fetuses the pelvic autonomic nerves are relatively thick. Thus the nerves stand out well against surrounding structures and their topographical relationships can exactly be determined. The inferior hypogastric plexus of 21-29-week old fetuses is situated on a curved line between the rectum and the ventrally adjacent structure. It constitutes a rectangular plate, which cannot be subdivided into individual plexuses for the different pelvic organs. The fetal plexus is heavily ganglionated. Large ganglia, forming the so-called ganglion of "Frankenhaeuser", are found in the female as well as in the male fetus. In the fetal pelvis the connective tissue compartments are still clearly arranged, because adipose tissue is not yet abundant. The greater part of the inferior hypogastric plexus is situated exactly at the border between a dense visceral tissue medially and a loose parietal tissue laterally. The plexus does not share a common connective tissue cover with the pelvic blood vessels. In fetuses the inferior hypogastric plexus lies in close vicinity to serveral organs, but the pelvic floor is the only region where the nerves can hardly be separated from the surrounding structures.

Staining of different tissues in thick epoxy resin-impregnated sections of human fetuses

Sections of undecalcified human fetuses, fixed in formaldehyde, embedded in the epoxy resin Biodur E 12 and cut on a diamond-wire saw were stained according to a slight modification of the method described by Laczkó and Lévai. The sections were immersed in a methylene blue/azure II solution at 90 C for at least 3 min and counterstained with a basic fuchsin solution at the same temperature. Differential staining was as follows: bone stained pinkish; cartilage, violet; collagen fibers, blue-violet; elastic fibers, red and muscle fibers, green-blue. Most other tissues were stained blue-violet against the transparent background of the embedding epoxy resin. Thanks to the distinct and differential staining of each tissue, contrast is sufficient for black and white as well as for color photography.

Tomographical anatomy of the pelvis, visceral pelvic connective tissue, and its compartments

The sectional anatomy of the pelvic connective tissue was studied in plastinated sections of fetal and adult pelves, by computed tomography and by magnetic resonance imaging. The comparative study of the different specimens shows that the pelvic connective tissue consists of three compartments: a presacral compartment, a perirectal compartment, and a paravisceral compartment. The content and the borders of the compartments are described. Furthermore the pelvic fasciae and the pelvic ligaments are studied within the different specimens. A thin pelvic visceral fascia can only be found around the perirectal compartment. In tomographical anatomy the so called supportive ligaments of the uterus are only composed of the round ligaments and the sacrouterine ligaments.

Tomographical anatomy of the pelvis, pelvic floor, and related structures

The sectional anatomy of the pelvic floor was studied in plastinated sections of adult pelves by computed tomography and by magnetic resonance imaging. In sectional anatomy, the levator ani is composed of three portions that can be clearly distinguished by their planes of cleavage and by the course of their fiber bundles. No muscular connections are found between the levator ani portions and the pelvic organs. The fascia of the levator ani in always interposed between the muscle and the pelvic organs. The sectional anatomy of the sphincter ani externus reveals a subdivision into a subcutaneous and a deep portion. Although the puborectalis portion of the levator ani and the deep portion of the sphincter ani externus are more or less continuous, in sectional anatomy they can be distinguished due to their different origins and attachments.

Anatomical considerations regarding the "bare spot" of the glenoid cavity

The "bare spot" of the glenoid cavity has recently been described as a constant reference point to quantify the amount of bone loss from the inferior portion of the glenoid cavity. In shoulder surgery this spot should help the surgeon to determine the width of the inferior portion of the glenoid cavity arthroscopically. The aim of this study was to determine the localization of the bare spot within the glenoid cavity and to prove its usefulness in shoulder surgery by means of a macroscopic study using embalmed glenohumeral joints ( n=20; 12 left, 8 right). Each glenoid cavity was photographed and transferred to a commercial AutoCAD software program. The bare spot was marked and the mean distances between the center of the bare spot and the inferior ( a), anterior ( b(1)) and posterior ( b(2)) inner margins of the glenoid labrum as well as its relationship ( c) to the mid-point of a virtual circle formed by the inferior portion of the glenoid cavity were measured (mean values : a=9.70, b(1)=10.88, b(2)=13.71, c=3.2 mm). In most cases, the bare spot showed a significantly excentric position within the inferior part of the glenoid cavity ( p<0.05). Due to the great variability in the shape of the glenoid cavity, an inferior circle according to previous descriptions could only be observed in half the specimens. From the results of our study the bare spot seems to be an unreliable landmark for the determination of the center of the inferior portion of the glenoid cavity, although it has a constant appearance and is probably expressed as the result of cartilaginous distribution due to dynamic shoulder activity.

Role of BDNF and neurotrophic receptors in human inner ear development

The expression patterns of the neurotrophin, brain-derived neurotrophic factor, BDNF, and the neurotrophic receptors-p75NTR and Trk receptors-in the developing human fetal inner ear between the gestational weeks (GW) 9 to 12 are examined via in situ hybridization and immunohistochemistry. BDNF mRNA expression was highest in the cochlea at GW 9 but declined in the course of development. In contrast to embryonic murine specimens, a decline in BDNF expression from the apical to the basal turn of the cochlea could not be observed. p75NTR immunostaining was most prominent in the nerve fibers that penetrate into the sensory epithelia of the cochlea, the urticule and the saccule as gestational age progresses. TrkB and TrkC expression intensified towards GW 12, at which point the BDNF mRNA localization was at its lowest. TrkA expression was limited to fiber subpopulations of the facial nerve at GW 10. In the adult human inner ear, we observed BDNF mRNA expression in the apical poles of the cochlear hair cells and supporting cells, while in the adult human utricle, the expression was localized in the vestibular hair cells. We demonstrate the highly specific staining patterns of BDNF mRNA and its putative receptors over a developmental period in which multiple hearing disorders are manifested. Our findings suggest that BDNF and neurotrophin receptors are important players during early human inner ear development. In particular, they seem to be important for the survival of the afferent sensory neurons.

Development of the levator ani muscle in human fetuses

The development of the levator ani muscle was studied in 300- to 700-microns thick sections through the pelves of 9- to 37-week-old fetuses and newborn children. During early fetal development, the anlage of the levator ani muscle can already be subdivided into three portions. The planes of cleavage between them become clearly evident in fetuses during the middle trimester when all points of origin and insertion of the levator ani muscle can be recognized. The tendinous arch of the pelvic fascia plays an important role in the differentiation between the pubococcygeus and the iliococcygeus parts of the levator ani muscle. The funnel-shaped form of the pelvic diaphragm is completed by about the 14th week of fetal development. Differences between the male and female levator ani muscles are already marked before birth.

The development of the external urethral sphincter in humans

OBJECTIVE

To assess the hypothesis that during fetal development, the external urethral sphincter changes from a concentric sphincter of undifferentiated muscle fibres to a transient ring of striated muscle which regresses caudo-cranially in the posterior urethra during the first year of life, when the sphincter assumes its omega-shaped configuration.

MATERIALS AND METHODS

The anatomy and development of the external urinary sphincter was assessed in human males and females during fetal life. Plastic-embedded sections (transverse, sagittal and frontal planes; 300-700 microm) of the pelvis of 31 females and 31 males (9 weeks of gestation to newborn) were stained with azure II/methylene blue/basic fuchsin and viewed at x 4-80. The sections of interest were taken from the bladder neck to the perineum. The sections of the membranous urethra were reconstructed three-dimensionally using a computer program.

RESULTS

In both male and female an omega-shaped external sphincter was apparent in all specimens at > 10 weeks of gestation. In the early fetal period (ninth week), there was undifferentiated mesenchyme; in this period the mesenchyme was more dense in the anterior part and loose in the posterior part of the urethra. In females, there was a close connection between the urethra and the anterior wall of the vagina.

CONCLUSION

The omega-shaped configuration of the external urethral sphincter was recognisable from 10 weeks of gestation in both sexes. There was no suggestion of a change from a cylindrical to an omega-shaped sphincter in the fetal period to birth. Also, a transient 'tail' posterior to the sphincter was not apparent. The rectovesical septum was well developed in neonates. There is no reason to assume that the development of the septum leads to an apoptosis of muscle cells in the posterior part of the external sphincter in males after birth. The anatomical development of the external sphincter does not explain transient outlet obstruction during fetal life. The function of the muscle may change during development because of neuronal maturation.

Anatomical considerations for transanal minimal-invasive surgery: the caudal to cephalic approach

AIM

Nerve-sparing surgery during laparoscopic rectal mobilization is still limited by anatomical constraints such as obesity, the narrowness of the male pelvis, an ultra low rectal cancer or all of these. The transanal approach for total mesorectal excision has overcome the shortcomings of limited access to the rectal 'no-man's land' close to the pelvic floor. The aim of this anatomical study was to define a roadmap of anatomical landmarks for the caudal to cephalic approach so as to standardize nerve-sparing rectal mobilization procedures.

METHOD

Macroscopic dissections of the pelvis in a caudal to cephalic direction were performed in eight alcohol-glycerol embalmed cadavers. A roadmap of anatomical landmarks was created at different levels of section to demonstrate the sites of nerve injury.

RESULTS

Extrinsic autonomic nerves to the urogenital organs and the internal sphincter muscle are closely adjacent to the lowest portion of the rectum above the pelvic diaphragm.

CONCLUSION

This anatomical guide for the pelvic surgeon should facilitate a safe and nerve-sparing dissection of the mesorectal plane with a meticulous overview of the lowest autonomic nerve fibres. New anatomical insights by a 'caudal to cephalic' approach to the 'no-man's land' should help overcome anatomical constraints of a narrow, obese and male pelvis during rectal mobilization procedures.

Stammzelltherapie der Harninkontinenz

Experimental and clinical studies investigated whether urinary incontinence can be effectively treated with transurethral ultrasound-guided injections of autologous myoblasts and fibroblasts.This new therapy was performed in eight female pigs. It could be shown that the injected cells survived well and that new muscle tissue was formed. Next, 42 patients (29 women, 13 men) suffering from urinary stress incontinence were treated. The fibroblasts were mixed with a small amount of collagen as carrier material and injected into the urethral submucosa to treat atrophies of the mucosa. The myoblasts were directly injected into the rhabdosphincter to reconstruct the muscle and to heal morphological and functional defects. In 35 patients urinary incontinence could be completely cured. In seven patients who had undergone multiple surgical procedures and radiotherapy urinary incontinence improved. No side effects or complications were encountered postoperatively. The experimental as well as the clinical data clearly demonstrate that urinary incontinence can be treated effectively with autologous stem cells. The present data support the conclusion that this new therapeutic concept may represent a very promising treatment modality in the future.

Cartilage canals in the chicken embryo: ultrastructure and function

In this study the detailed morphology and the function of cartilage canals in the chicken femur are investigated. Several embryonic stages (e 13.5, 16, 19, and 20) are examined by means of light microscopy, electron microscopy (TEM), and immunohistochemistry (VEGF, type I and II collagen). Our results show that cartilage canals originate from the perichondrium and form a complex pattern. Two types of canals are distinguishable: shell canals and communicating canals. Shell canals are in the reserve zone and are arranged in successive layers. Communicating canals spring from the shell canals and pass down into the proliferative zone and into the hypertrophic zone. These canals are conical shaped and are orientated nearly in parallel to the long axis of the femur. Cartilage canals comprise venules, arterioles, capillaries (mature and immature), and undifferentiated mesenchymal cells. No canal wall in the sense of an epithelium is elaborated. VEGF is detected in both types of canals and macrophages are found at the end of the cartilage canals. We conclude that the growth factor stimulates angiogenesis and that the latter cells erode the matrix ahead of the canals and thus enable the advancement of the vessels. The results clearly show that the canal matrix differs from the remaining cartilage matrix. The canal matrix contains type I collagen, few type II collagen fibrils and proteoglycans are lacking. In contrast, in the cartilage matrix type II collagen and proteoglycans are abundant but no type I collagen is found. Communicating canals are surrounded by a distinct layer of type I collagen indicating that osteoid is formed around these canals. Hypertrophic chondrocytes label for type I collagen and it seemed possible that chondrocytes adjacent to the communicating canals differentiate into bone-forming cells. Our results provide evidence that cartilage canals are involved in nourishment of the cartilage as well as in the ossification process.

Colloid cysts--a review including 19 own cases

Between 1974 and 1987 19 patients harbouring colloid cysts of the third ventricle have been treated in our department. There were 12 male and 7 female patients with an average age of 34 years (ranging from 17 to 58). Eighteen of the 19 patients underwent direct microsurgical removal of the space occupying lesion using the transcortical-transventricular approach. One patient had placement of a ventriculoperitoneal shunt and declined further treatment. There were no deaths in the entire series and no permanent neurological deficits were observed postoperatively. Surgery was successful in unblocking CSF pathways in 12 patients; six patients required permanent CSF diversion. Considering the advantages and disadvantages of various surgical modalities for the treatment of the lesions we recommend the microsurgical removal of the colloid cyst using the transcortical-transventricular approach.

Cross-sectional imaging anatomy of the anal sphincters

BACKGROUND

To describe the cross-sectional anatomy of the anal sphincter mechanism relevant to magnetic resonance imaging (MRI) and ultrasound cross-sectional images.

METHOD

Axial, sagittal, and coronal 5-mm sections of female pelves were reviewed from six cadaver specimens (ages 24-72 years). Fetal anatomy was studied in plastinated histologic sections from 19 and 26 weeks' gestation. Images of the anal sphincter were obtained by MRI in six and by ultrasound using an exoanal technique in 12 nulliparous volunteers.

EXPERIENCE

The internal anal sphincter is clearly visible in anatomic sections central to the external sphincter and is visible in MRI and ultrasound images. The external anal sphincter can be subdivided into a subcutaneous and a deep portion. On anatomic sections and on MRI, the subcutaneous part shows as two parallel muscle strips in the axial plane; the deep portion presents with a characteristic teardrop form in the section perpendicular to the axis of the anal canal. The puborectalis muscle and the external anal sphincter form a "double bump" in the sagittal section. The longitudinal muscle can be identified by its fiber orientation in anatomic sections but is not clearly visible in imaging studies.

CONCLUSION

This information should make it possible to identify accurately anal sphincter anatomy in two-dimensional sectional images of the anal sphincter.

Vascular considerations for stapled haemorrhoidopexy

OBJECTIVE

Modern haemorrhoidectomy techniques aim to interrupt arterial blood supply to the hypertrophied piles. The aim of this study was to investigate morphological and physiological alterations in the terminal branches of the superior rectal artery (SRA) in patients with haemorrhoidal disease treated by stapled haemorrhoidopexy (SH) using noninvasive transperineal ultrasound.

METHOD

Thirty-seven consecutive patients (14 women, 23 men; median age 52, range 30-77 years) who underwent SH for treatment of grade III haemorrhoids were scanned by transperineal colour Doppler ultrasound at baseline, 4 weeks and 3 months postoperatively. Seventeen healthy volunteers served as the control group (nine women, eight men; median age 24, range 18-72 years). Calibre and arterial flow velocity (AFV) of the terminal branches of the SRA were measured.

RESULTS

Baseline measurements significantly differed between patients and the control group (median calibre 2, range 0.9-3.6 mm, vs 1, range 0.6-1.2 mm, and median AFV 24, range 10-65 cm/s, vs 12, range 5-21 cm/s, P < 0.0001). Postoperative follow-up showed no significant alterations in the physiological parameters. Patients with a higher recurrence rate of haemorrhoidal disease had higher baseline AFV values.

CONCLUSION

Stapled haemorrhoidopexy does not reduce arterial inflow in the feeding vessels of the anorectal vascular plexus. Preoperative ultrasound may serve as a tool for assessing vascularization status in haemorrhoidal disease and is useful in deciding whether patients should undergo SH or, for individuals with high AFV, whether conventional haemorrhoidectomy might be the better choice.

The connective tissue sheath of uterus and vagina in the human female fetus

A morphological study concerning the development and arrangement of the connective tissue surrounding uterus and vagina was performed by investigating epoxy resin impregnated sections through the pelves of 9-37-week-old female fetuses, of newborn children and a three-year-old child. In order to study the histology of the connective tissue in detail paraffin, semithin and ultrathin sections were used. The organization of the pelvic connective tissue in female fetuses can best be studied in middle-aged fetuses (19-28 weeks of gestation). We here report that no supportive ligaments of the uterus are found in fetuses of that age group, but that the connective tissue covering uterus and vagina is part of the connective tissue sheaths of neighbouring structures. The fetal uterus is interposed between dense subperitoneal connective tissue circularly covering the vesico- and rectouterine pouch. Dorsally the subperitoneal tissue of the rectouterine pouch joins the circularly arranged connective tissue of the rectal adventitia. A triangularly-shaped plate of dense connective tissue is situated at each lateral border of the cervix uteri. Dorsally it is continuous with the circularly running fibres of the rectouterine pouch. Whereas the dorsal wall of the vagina is loosely connected with the rectal adventitia, fibrous connective tissue intimately fuses the muscular wall of the vagina with that of the neck of the bladder and of the urethra. No evidence is provided for the existence of smooth muscle cells and elastic material within the connective tissue covering the fetal uterus.

Anatomic survey of the common fibular nerve and its branching pattern with regard to the intermuscular septa of the leg

Compression syndromes of the common fibular nerve and its branches frequently occur primarily as well as secondarily to trauma and surgery. A keen knowledge of the course and the relationship of the deep fibular nerve to adjacent anatomical structures in the proximal leg is mandatory. Previous literature often lacks detailed information on the course of the deep fibular nerve and is based on a limited number of observations. The aim of this study was to investigate the common fibular nerve and its branching pattern with special regard to the relationship between the deep fibular nerve and the anterior intermuscular septum of the leg. Variations in the course of the fibular nerve were demonstrated. The fibular compartments of the leg (n = 111) were dissected in 57 embalmed cadavers and included: 1) investigation of the number of muscular branches; 2) entering passages to the respective compartments of the leg; and 3) the relationship between the fibularis longus muscle and the deep fibular nerve. The most proximal muscular branch of the deep fibular nerve directly "pierced" the anterior intermuscular septum of the leg. Narrow passages within the fibular compartment and, in consequence, areas of possible higher incidence of nerve compression were suggested at the level of the intermuscular septa of the leg, between the two distinct portions of the fibularis longus muscle and the crossing of the supplying vessels. There were hardly ever statistically significant differences between the two sides or male and female gender. According to our results, the anterior intermuscular septum of the leg may be regarded as an important landmark for the surgeon when dissecting the muscular branches of the deep fibular nerve. The variable branching pattern of the deep fibular nerve within the fibular compartment of the leg should be taken into account.

Topography and subdivision of the pelvic connective tissue in human fetuses and in the adult

We investigated epoxy resin impregnated sections through the pelves of 9 to 37-week-old fetuses, of newborn infants, and of adults to study the topography and subdivision of the pelvic connective tissue. Fetal and adult preparations show that the pelvic connective tissue can be subdivided into a presacral, a perirectal and a paravisceral compartment. Whereas the presacral and the perirectal compartment contain connective tissue, adipose tissue and supplying structures, the paravisceral compartment is mainly composed of adipose tissue. While only a very thin rectal fascia was found at the border of the perirectal compartment, no further visceral pelvic fascia can be seen in the impregnated sections. Moreover it is shown that the ligaments of the pelvic cavity are only composed of the sacrouterine ligaments and the pubovesical ligaments in the female and the puboprostatic ligaments in the male. Our data show that sectional anatomy provides new insights into the organization of the pelvic connective tissue, that may be of clinical importance.

Accuracy of concepts in female pelvic floor anatomy: facts and myths!

The pelvic floor is characterized by a complex morphology because different functional systems join here. Since a clear understanding of the pelvic floor region is crucial for female pelvic surgery and fundamental mechanisms of urogenital dysfunction and treatment, we here describe the accurate and functional anatomy of important pelvic structures and landmarks, clarify their terminology and point out possible errors or misunderstandings as to their existence.

Development and distribution of adipose tissue in the human pelvis

The development of the pelvic adipose tissue was studied using 300-600 microns thick sections through the pelves of 9-37-week-old fetuses and newborn children. During fetal life three different anlagens of adipose tissue appear within the pelvic cavity. Development and topography of these anlagens are described, and correlations with the development of the connective tissue compartments within the pelvis were demonstrated.

Radiological signs of Leri-Weill dyschondrosteosis in Turner syndrome

BACKGROUND/AIMS

Leri-Weill dyschondrosteosis (LWD), a mesomelic short stature syndrome with Madelung deformity, was recently reported to be caused by SHOX (short stature homeobox-containing gene) haploinsufficiency. The loss of SHOX on Xp22.32, also called PHOG (pseudoautosomal homeobox-containing osteogenic gene), through structural aberrations of the X chromosome was also implicated in the short stature phenotype and some additional stigmata of Turner syndrome. The aim of this study was to systematically examine left-hand radiographs from Turner girls for the presence of signs of LWD.

METHODS

We retrospectively studied 168 left-hand radiographs from 54 patients with Turner syndrome (bone age >10.5 years) who were treated with rhGH and seen during the last 10 years in our clinic. For comparison, we analyzed 7 radiographs from 5 patients with LWD and 52 radiographs from 20 patients with GH deficiency. The shape of the distal radial epiphysis (triangularisation index = TI) and the carpal angle were quantitatively measured. In addition, we screened for the presence of a premature cleft fusion or an ulnar deviation of the articular surface of the distal radial epiphysis and for fourth metacarpal shortening. One of 54 Turner girls (2%) was affected with LWD and presented with Madelung deformity.

RESULTS

No milder forms of Madelung deformity were detected. However, there was a significant trend to a triangular shape of the distal radial epiphysis in Turner syndrome: the median TI was 2.7 in normal controls (range 1.8-3.7), 3.1 in Turner girls (range 2.0-6.3) (p < 0.001 against controls), and 6.0 in patients with LWD (range 3.5-11.0) (p < 0.001 against controls).

CONCLUSIONS

The triangularisation index did not correlate with the carpal angle (median 122.5