Storm Event-Driven Occurrence and Transport of Dissolved and Sorbed Organic Micropollutants and Associated Effects in the Ammer River, Southwestern Germany

Storm events lead to agricultural and urban runoff, to mobilization of contaminated particulate matter, and to input from combined sewer overflows into rivers. We conducted time-resolved sampling during a storm event at the Ammer River, southwest Germany, which is representative of small river systems in densely populated areas with a temperate climate. Suspended particulate matter (SPM) and water from 2 sampling sites were separately analyzed by a multi-analyte liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for 97 environmentally relevant organic micropollutants and with 2 in vitro bioassays. Oxidative stress response (AREc32) may become activated by various stressors covering a broad range of physicochemical properties and induction of aryl hydrocarbon receptor-chemical-activated luciferase gene expression (AhR-CALUX) by hydrophobic compounds such as dioxins and dioxin-like molecules. Compound numbers, concentrations, their mass fluxes, and associated effect fluxes increased substantially during the storm event. Micropollutants detected in water and on SPM pointed toward inputs from combined sewer overflow (e.g., caffeine, paracetamol), urban runoff (e.g., mecoprop, terbutryn), and agricultural areas (e.g., azoxystrobin, bentazone). Particle-facilitated transport of triphenylphosphate and tris(1-chloro-2-propyl) phosphate accounted for up to 34 and 33% of the total mass flux even though SPM concentrations were <1 g L^-1 . Effect fluxes attributed to SPM were similar or higher than in the water phase. The important role of SPM-bound transport emphasizes the need to consider not only concentrations but also mass and effect fluxes for surface water quality assessment and wastewater/stormwater treatment options. Environ Toxicol Chem 2021;40:88-99. © 2020 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Influence of Emission Sources and Tributaries on the Spatial and Temporal Patterns of Micropollutant Mixtures and Associated Effects in a Small River

Organic micropollutants of anthropogenic origin in river waters may impair aquatic ecosystem health and drinking water quality. To evaluate micropollutant fate and turnover on a catchment scale, information on input source characteristics as well as spatial and temporal variability is required. The influence of tributaries from agricultural and urban areas and the input of wastewater were investigated by grab and Lagrangian sampling under base flow conditions within a 7.7-km-long stretch of the Ammer River (southwest Germany) using target screening for 83 organic micropollutants and 4 in vitro bioassays with environmentally relevant modes of action. In total, 9 pesticides and transformation products, 13 pharmaceuticals, and 6 industrial and household chemicals were detected. Further, aryl hydrocarbon receptor induction, peroxisome proliferator-activated receptor activity, estrogenicity, and oxidative stress response were measured in the river. The vast majority of the compounds and mixture effects were introduced by the effluent of a wastewater-treatment plant, which contributed 50% of the total flow rate of the river on the sampling day. The tributaries contributed little to the overall load of organic micropollutants and mixture effects because of their relatively low discharge but showed a different chemical and toxicological pattern from the Ammer River, though a comparison to effect-based trigger values pointed toward unacceptable surface water quality in the main stem and in some of the tributaries. Chemical analysis and in vitro bioassays covered different windows of analyte properties but reflected the same picture. Environ Toxicol Chem 2020;39:1382-1391. © 2020 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Mitochondrial Toxicity of Selected Micropollutants, Their Mixtures, and Surface Water Samples Measured by the Oxygen Consumption Rate in Cells

Some environmental pollutants impair mitochondria, which are of vital importance as energy factories in eukaryotic cells. Mitochondrial toxicity was quantified by measuring the change of the oxygen consumption rate (OCR) of HepG2 cells with the Agilent Seahorse XF^e 96 Analyzer. Various mechanisms of mitochondrial toxicity, including inhibition of the electron transport chain or adenosine triphosphate (ATP) synthase as well as uncoupling of oxidative phosphorylation, were differentiated by dosing the sample in parallel with reference compounds following the OCR over time. These time-OCR traces were used to derive effect concentrations for 10% inhibition of the electron transport chain or 10% of uncoupling. The low effect level of 10% was necessary because environmental mixtures contain thousands of chemicals; only few of them interfere with mitochondria, but the others cause cytotoxicity. The OCR bioassay was validated with environmental pollutants of known mechanism of mitochondrial toxicity. Binary mixtures of uncouplers or inhibitors acted according to the mixture model of concentration addition. Uncoupling and/or inhibitory effects were detected in extracts of river water samples without apparent cytotoxicity. Uncoupling effects could only be quantified in water samples if inhibitory effects occurred at lower concentrations because no uncoupling can be detected without an appreciable membrane potential built up. The OCR bioassay can thus complement chemical analysis and in vitro bioassays for monitoring micropollutants in water. Environ Toxicol Chem 2019;00:1-12. © 2019 SETAC.

Combining in vitro reporter gene bioassays with chemical analysis to assess changes in the water quality along the Ammer River, Southwestern Germany

BACKGROUND

Rivers receive water and associated organic micropollutants from their entire catchment, including from urban, agricultural and natural sources, and constitute an important environmental component for catalyzing pollutant turnover. Environmental removal processes were extensively investigated under laboratory conditions in the past but there is still a lack of information on how organic micropollutants attenuate on the catchment scale. The aim of this study was to describe the chemical and toxicological profile of a 4th order river and to characterize in-stream processes. We propose indicator chemicals and indicator in vitro bioassays as screening methods to evaluate micropollutant input and transport and transformation processes of the chemical burden in a river. Carbamazepine and sulfamethoxazole were selected as indicators for dilution processes and the moderately degradable chemicals tramadol and sotalol as indicators for potential in-stream attenuation processes. The battery of bioassays covers seven environmentally relevant modes of action, namely estrogenicity, glucocorticogenic activity, androgenicity progestagenic activity and oxidative stress response, as well as activation of the peroxisome proliferator-activated receptor and the aryl hydrocarbon receptor, using the GeneBLAzer test battery and the AhR-CALUX and AREc32 assays.

RESULTS

Both approaches, targeted chemical analysis and in vitro bioassays, identified a wastewater treatment plant (WWTP) as a major input source of organic micropollutants that dominantly influenced the water quality of the river. Downstream of the WWTP the amount of detected chemicals and biological effects decreased along the river flow. The organic indicator chemicals of known degradability uncovered dilution and potential loss processes in certain river stretches. The average cytotoxic potency of the river water decreased in a similar fashion as compounds of medium degradability such as the pharmaceutical sotalol.

CONCLUSIONS

This study showed that the indicator chemical/indicator bioassay approach is suitable for identifying input sources of a mixture of organic micropollutants and to trace changes in the water quality along small rivers. This method forms the necessary basis for evaluating the natural attenuation processes of organic micropollutants on a catchment scale, especially when combined with enhanced sampling strategies in future studies.

[The medical-psychiatric unit: added value for patients, physicians and hospitals]

Physical and mental illnesses commonly occur together. The quality of physical care in institutions for mental health in the Netherlands is not guaranteed. The cases of a 63-year-old woman with a schizoaffective disorder and diabetes mellitus who became delirious after surgery and a 76-year-old suicidal man with a psychotic disorder due to hydrocobalamine deficiency after major heart surgery show that the so-called medical-psychiatric unit, which is a part of the Psychiatric Department of a general hospital, may have several advantages in the treatment of combined physical and mental disorders. Both patients were admitted to such a unit. In this way, the internist of the first patient could continue to treat her and she could be treated with an infusion, urinary catheter and gastric intubation; in addition, laboratory investigations could be performed. The second patient, whose safety required primary attention, could also be treated for his somatic disorders and a delirium could be ruled out. His family was assisted in recovering from their traumatic life experience caused by his suicide attempt.

The management of severe acetabular bone loss using structural allograft and acetabular reinforcement devices

The cases of 37 acetabular reconstructions in 35 patients with major structural pelvic bone loss were reviewed. At an average follow-up of 7.1 years, patients rated their results as excellent in 12 cases (32.4%), good in 22 (59.5%), fair in 2 (5.4%), and poor in 1 (2.7%). Thirty-four cases (91.9%) were classified as a clinical success. Thirty-six allografts (97.3%) had radiographic evidence of full incorporation. Of the unrevised hips, 1 (2.7%) was classified as definitely loose, 2 (5.4%) as probably loose, and 4 (10.8%) as possibly loose. One revision of an acetabular component was required because of late sepsis. This is the first reported series on the use of acetabular reinforcement devices with solid bulk allograft covering more than 50% of the socket. The allograft is protected in the early postoperative period, superior migration of the cup is virtually eliminated as a complication, and the incidence of aseptic loosening is greatly diminished.

Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip

We reviewed 508 consecutive total hip replacements in 370 patients with old developmental dysplasia of the hip, to relate the amount of leg lengthening to the incidence of nerve palsies after operation. There were eight nerve palsies (two femoral, six sciatic), two complete and six incomplete. We found no statistical correlation between the amount of lengthening and the incidence of nerve damage (p = 0.47), but in seven of the eight hips, the surgeon had rated the intervention as difficult because of previous surgery, severe deformity, a defect of the acetabular roof, or considerable flexion deformity. The correlation between difficulty and nerve palsy was significant (p = 0.041). We conclude that nerve injury is most commonly caused by direct or indirect mechanical trauma and not by limb lengthening on its own.

The Bürch-Schneider anti-protrusio cage in revision total hip arthroplasty: indications, principles and long-term results

Patients who had a revision total hip arthroplasty using the Bürch-Schneider anti-protrusio cage (APC) by a single surgeon have been reviewed after a minimum of five years. There were 63 operations in 58 patients with an average age of 63 years (41 to 83) at the time of revision. At an average follow-up of 8.5 years (5 to 18), 15 patients (25.9%) rated their results as excellent, 38 (65.5%) as good, and five (8.6%) as fair. Five further revisions of the acetabular prosthesis were required, three due to aseptic loosening, one for recurrent dislocation and one due to sepsis. Of the remainder, one was definitely loose, two probably loose, and 12 possibly so. Impressive augmentation of bone stock can be achieved with the anti-protrusio cage, while enabling the hip to be centred in its anatomical position.

Total hip arthroplasty with use of an acetabular reinforcement ring in patients who have congenital dysplasia of the hip. Results at five to fifteen years

The purpose of our study was to examine the clinical and technical problems associated with reconstruction of the hip in patients who had congenital dysplasia and to offer recommendations for their solution. We reviewed the records on 123 consecutive total hip arthroplasties that had been performed by one of us (M. E. M.), between 1981 and 1986, for the treatment of coxarthrosis due to congenital dysplasia of the hip. A minimum of five years of follow-up was required for inclusion in the study. The study group consisted of seventy patients who had had a total of eighty-seven reconstructions. According to the classification of Crowe et al., eleven hips had type-IV acetabular dysplasia; sixty-five, type-II; and eleven, type-II. Acetabular reconstruction was performed with use of the Müller acetabular roof-reinforcement ring and a polyethylene cup, which was inserted with cement. Autologous graft from the femoral head was used in forty-two hips. Femoral reconstruction was performed with use of the Müller straight-stem component for congenital dysplasia of the hip in eighty hips and with use of a standard Müller straight-stem component in seven hips. At an average of 9.4 years (range, five to fifteen years) postoperatively, the result was described as excellent for sixty hips (69 per cent), as good for twenty-three (26 per cent), as fair for two (2 per cent), and as poor for two. Nine (10 per cent) of the hips had been revised. One revision had been performed because of aseptic loosening of the acetabular component; one, because of aseptic loosening of the femoral component; one, because of aseptic loosening of both components; and six, because of infection. Of the unrevised hips, three had had superior migration of the acetabular component of less than five millimeters, and mild protrusion had developed in one. Two hips had a continuous radiolucent line around the acetabular construct. Two hips had had subsidence of the femoral stem of less than three millimeters; one had a complete, non-progressive radiolucent line at the bone-cement interface; and four had a radiolucent line at the proximal part of the bone-cement interface. Six hips had evidence of endosteal osteolysis. Six hips had grade-III or IV heterotopic ossification according to the system of Brooker et al. These results compare favorably with others in the literature. We recommend restoration of the anatomical hip center with the use of an acetabular roof-reinforcement ring and a polyethylene cup inserted with cement for the reconstruction of a deficient acetabulum. The acetabular reinforcement ring prevents resorption of bone graft and migration of the cup, which are major causes of failure of the cup in patients who have had a reconstruction of a deficient acetabulum. Bone graft should be used medially and superiorly as needed to augment bone stock notably. Cement should not be used to fill acetabular defects as we believe that it contributes to aseptic loosening.

The value of preoperative planning for total hip arthroplasty

To analyse the value and accuracy of preoperative planning for total hip replacement (THR) we digitised electronically and compared the hand-sketched preoperative plans with the pre- and postoperative radiographs of 100 consecutive primary THRs. The correct type of prosthesis was planned in 98%; the agreement between planned and actually used components was 92% on the femoral side and 90% on the acetabular side. The mean (+/- SD) absolute difference between the planned and actual position of the centre of rotation of the hip was 2.5 +/- 1.1 mm vertically and 4.4 +/- 2.1 mm horizontally. On average, the inclination of the acetabular component differed by 7 +/- 2 degrees and anteversion by 9 +/- 3 degrees from the preoperative plans. The mean postoperative leg-length difference was 0.3 +/- 0.1 cm clinically and 0.2 +/- 0.1 cm radiologically. More than 80% of intraoperative difficulties were anticipated. Preoperative planning is of significant value for the successful performance of THR.

Total hip arthroplasty after previous proximal femoral osteotomy

We compared 74 total hip arthroplasties (THAs) carried out after previous proximal femoral osteotomy with a diagnosis-matched control group of 74 primary procedures performed during the same period. We report the perioperative results and the clinical and radiological outcome at five to ten years. We anticipated a higher rate of complications in the group with previous osteotomy, but found no significant difference in the rate of perioperative complications (11% each) or in the septic (8% v 3%) and aseptic (4% each) revision rates. There was a trend towards improved survival in the group without previous osteotomy (90% v 82%), but this difference was not statistically significant. The only significant differences were a higher rate of trochanteric osteotomy (88% v 14%) and a longer operating time in the osteotomy group. Our study indicates that THA after previous osteotomy is technically more demanding but not necessarily associated with a higher rate of complications. Furthermore, proximal femoral osteotomy does not jeopardize the clinical and radiological outcome of future THA enough to exclude the use of osteotomy as a therapeutic alternative in younger patients.

Prenatal and postnatal attachment: a modest correlation

OBJECTIVE

To determine whether a correlation exists between prenatal and postnatal attachment.

DESIGN

Prospective, correlational study with data collected during the second half of pregnancy and again 1-2 months after delivery.

SETTING/PARTICIPANTS

Two hundred twenty-eight women were recruited from childbirth education classes. The women were generally young, white, well educated, married, and employed.

MAIN OUTCOME MEASURES

The Prenatal Attachment Inventory (PAI) was used to measure attachment before birth. The Maternal Attachment Inventory (MAI), the How I Feel About my Baby Now Scale, and the Maternal Separation Anxiety Scale were used to measure attachment after birth.

RESULTS

One hundred ninety-six women completed all the measures. A correlation was found between PAI and MAI scores (r = 0.41, p < 0.001).

CONCLUSIONS

A correlation between prenatal and postnatal attachment was found. However, the modest size of the correlation indicated that other factors also influenced postnatal scores. Thus, caution should be exercised when promoting increased prenatal attachment in hopes of improving postnatal attachment.

The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome

To help to determine the natural history of residual dysplasia of the hip after skeletal maturity, we followed the status of the contralateral hip in 286 patients who had had a total hip replacement for osteoarthrosis secondary to dysplasia. The initial radiographic findings in seventy-four patients in whom advanced osteoarthrosis later developed in the contralateral hip were compared with those in forty-three patients who had reached the age of sixty-five years without having had severe osteoarthrosis. No patient in whom the hip functioned well until the age of sixty-five years had had a center-edge angle of less than 16 degrees, an acetabular index of depth to width of less than 38 per cent, an acetabular index of the weight-bearing zone of more than 15 degrees, uncovering of the femoral head of more than 31 per cent, or an acetabulum in which the most proximal point of the dome had been at the lateral edge (zero peak-to-edge distance).

The benefits of metal-on-metal total hip replacements

The Müller's cast prosthesis with a concentric metal-on-metal articulation and 3 sliding bearings was used in Switzerland from 1965 to 1967. During the next 10 to 15 years, a number of hips in which the metal-to-metal systems were implanted were revised. Rather than osteoporosis and cranial migration occurring, the acetabular roofs were often sclerotic and the components showed no or only minor migration. At surgery, the capsule was almost normal and without signs of inflammation. Histologically, the capsule did not show the usual masses of giant cells associated with polyethylene particles. In the mid-1980s, different designs of metal-on-metal articulations were tested. From 1987 to 1990, this author developed, together with the biomaterial division of Sulzer Medical Technology, a pure titanium shell with a polyethylene-backed 28-mm forged cobalt-chromium liner insert. This combination has been successful, with no revisions required to date. In summary, with the present metal-on-metal articulations it is now possible to stop using the polyethylene. The successful long-term results of the cast cobalt-chromium metal-on-metal articulations of 1966 hold much promise for the future of the new-forged, more-precise, metallic socket.

Chevron osteotomy and single wire reattachment of the greater trochanter in primary and revision total hip arthroplasty

Even at a medical center where hip arthroplasty is performed routinely without trochanteric osteotomy, selected arthroplasties still require greater trochanteric osteotomy. A technique of greater trochanteric biplane osteotomy and reattachment with one wire is described. The technique provides maximum stability with a minimum of internal fixation and it can be performed quickly. The postoperative rehabilitation protocol is the same as that used in hip arthroplasty patients without trochanteric osteotomy. Results with a minimum two-year follow-up period disclosed osseous union in 98% of 53 primary arthroplasties and 97% of 74 revision hip arthroplasties. Problems related to the greater trochanter necessitated reoperation in only two patients: one for reattachment of a migrated trochanter and one for trochanteric wire removal.

Factor analysis of the Maternal Fetal Attachment Scale

The purpose of this study was to assess the validity of the Maternal Fetal Attachment Scale (MFAS) subscales using factor analysis. The 23-item MFAS is composed of five subscales that have been used to represent the theorized dimensions of prenatal attachment. Two samples of MFAS scores were submitted to principal axis factoring with varimax rotation. The resulting solutions failed to correspond to the subscales of the MFAS and were also different from one another. These results indicate that the use of the MFAS subscales, as currently constructed, is problematic.

The power of the name

An integral part of any research study is the assignment of names to phenomena of interest. The linguistic nuances accompanying names are frequently neglected, with a resulting significant affect on nursing research and on the tenor of nursing knowledge. Concept analysis is an important strategy for surmounting the difficulties associated with the process of choosing and modifying names. Examples of the naming process in two areas of nursing research are used to illustrate the influence of concept analysis on the development of nursing knowledge.

Revision arthroplasty using an anti-protrusio cage for massive acetabular bone deficiency

Revision hip arthroplasty in patients with massive acetabular bone deficiency has generally given poor long-term results. We report the use of an 'anti-protrusio cage', secured to the ischium and ilium, which bridges areas of acetabular bone loss, provides support for the acetabular socket, and allows pelvic bone grafting in an environment protected from excessive stress. Forty-two failed hip arthroplasties with massive acetabular bone loss were revised with the Burch-Schneider anti-protrusio cage and evaluated after two to 11 years (mean five years). There was failure due to sepsis in five hips (12%) and aseptic loosening in five (12%); the remaining 32 hips (76%) showed no evidence of acetabular component failure or loosening.

Lessons of 30 years of total hip arthroplasty

The following are lessons of 30 years of total hip arthroplasty (THA): Prosthetic components should allow for easy preoperative graphic planning with one or two templates only. Polyethylene is the weak link in THA and ought to be replaced by perfectly concentric metallic sockets and femoral heads of casted Cr/Co/Mo alloys. The operating technique should guarantee large exposure, suitable orientation of both components, and adequate fixation. Loosening is correlated with loss of bone stock and changes of the position of the implants. In case of progressive bone loss, one should reoperate already in presence of slight clinical symptoms to prevent more difficult and dangerous revisions. To evaluate objectively the outcome of THA, a combined data and roentgenographic documentation system with standardized terms and scales is necessary.

Automated scanning and digitizing of roentgenographs for documentation and research

A comprehensive system has been developed for analyzing and reporting the results of total hip arthroplasty. The personal-computer-based system links patient demographic data with digital storage, retrieval, and analysis of roentgenographs. The system consists of a roentgenograph scanner for converting sheet film to digital data, an optical mark reader for patient data input, an archiving system with optical storage, and a physician display station for preoperative planning and postoperative evaluation. Once a roentgenograph has been digitized and stored, the image can be retrieved and manipulated in a manner not possible with the original sheet film. A selected roentgenograph can be brought to full or enlarged scale, enhanced, and overlaid with templates for preoperative planning or for postoperative measurement of changes. In addition, an intelligent database system has been developed for linking patient demographic information with the roentgenographic data. The database system employs uniform criteria and terminology and allows the retrospective study and statistical analysis of comparable cases. Three machine-readable code sheets are used: Form A, Replacement of the Hip; Form B, Hip Prosthesis Reoperation; and Form C, Follow-up. Forms A and B contain information concerning anamnesis, diagnosis, treatment, postoperative course, recovery, and discharge of the patient from the hospital. Form C provides information on physical examination, pain, mobility of the hip, walking ability, and evaluation of the results by the surgeon as well as the patient.

Effects of terbutaline and atenolol on large and small airways in asthmatic patients

In order to localize the main site of action of the beta 2-adrenoceptor selective agonist terbutaline and the beta 1-adrenoceptor selective antagonist atenolol in the airways of asthmatic patients, we compared the effects of these drugs on maximal expiratory flow-volume (MEFV) curves when breathing air and when breathing a helium-oxygen (HeO2) mixture. To investigate whether a shift in localization of the bronchodilator effect occurs when terbutaline is inhaled repeatedly, dose-response curves with terbutaline were performed for parameters derived from MEFV curves when breathing air and for density dependence of expiratory airflow. By measurement of MEFV curves when the patients were breathing air alone, it was not possible to determine whether there is a difference in the bronchoconstrictor effect of atenolol between large and small airways. Inhalation of terbutaline to a cumulative dose of 2.0 mg induced a stepwise improvement in expiratory airflow parameters for large and small airways function when breathing air. Doubling the dose of inhaled terbutaline to 4 mg did not result in any further improvement of lung function. Neither atenolol nor terbutaline induced significant mean changes in density dependence of expiratory airflow. This was partly due to large inter- and intra-individual variations of this parameter. Another possibility is that atenolol and terbutaline effect large and small airways function equally.

Anatomic basis of the transgluteal approach to the hip

In order to define the technical modalities of the so-called transgluteal approach to the hip, the authors studied the structure and topography of the anatomic features encountered in this approach. The gluteus medius, gluteus minimus and vastus lateralis muscles are anatomically continuous by way of their tendinous fibers. The gluteus minimus muscle winds over the cranial and then anterolateral aspect of the capsule, to which it is bound by fibrous tracts and tendinous expansions; its terminal tendon blends its fibers with the anterior part of the tendon of the gluteus medius and enters into continuity with the superficial tendinous fibers of the anterior part of the vastus lateralis. The zone of junction of the three muscle structures is closely bound to the anterior aspect of greater trochanter. The caudal neurovascular trunk of the space between the gluteus medius and vastus lateralis is situated at a distance of 3 to 5 cm from the greater trochanter. The practical surgical implications are discussed, particularly as regards the methods of dissecting the anterior margin of the transgluteal incision, exposure of the capsule and preservation of the neurovascular pedicle, with reference to concepts published previously in studies elsewhere.

A comparative study on the ventilatory and haemodynamic effects of xamoterol and atenolol in asthmatic patients

The effects of single oral doses of atenolol 50 mg and xamoterol 200 mg (a recently developed partial beta 1-adrenoceptor agonist) on lung function, heart rate and blood pressure were investigated in 11 patients with asthma. Xamoterol caused a significant increase in heart rate and systolic blood pressure, which changes are consistent with the partial beta 1-adrenoceptor agonist activity of this drug. Atenolol induced a significant decrease in FEV1 and the forced vital capacity (FVC); there was a non-significant change in FEV1 and FVC after xamoterol. There was no significant difference between the effects of atenolol and xamoterol of FEV1 and FVC. Bronchospasm induced by atenolol 50 mg and xamoterol 200 mg was completely reversed by inhalation of the beta 2-adrenoceptor agonist terbutaline to a cumulative dose of 4.0 mg.

Chiari's osteotomy. A note on technique

Direct joint distraction of the hip facilitates the performance of Chiari's osteotomy on a standard operating table as opposed to the classic procedure on the traction table. Some useful modifications of the original technique include a guide wire to control the direction of the osteotomy, insertion of an additional bone graft to provide better anterior coverage of the head, and internal fixation of the osteotomy.

[Morphology and clinical aspect of the lateral ligaments of the ankle joint (author's transl)]

The direction of movement and the range of movement of a joint are determined by the lengths of the ligaments and the positions of their origins and insertions. It follows that any operation which alters the length of a ligament or moves one of its points of attachment is unphysiological. Reconstruction should be carried out with due regard to the normal anatomy. In the ankle joint, for example, the tip of the lateral malleolus should be left free of ligamentary insertions. Until now, anatomical illustrations have shown the lateral ligaments of the ankle joint to be attached to the anterior border of the fibula and to its anterior and lateral surface. All the older illustrations emphasize a band of fibers which passes directly from the neck of the talus to the calcaeus. This band varies in thickness and always forms the base of the triangle formed by the anterior talofibular ligament and the calcaneofibular ligament. Examination of surgical specimens and amputated ankle joints shows that the lateral tip of the fibula is free of ligamentary insertions. The lateral fibular ligaments are attached to the distal end of the fibula around the border of the cartilaginous foint surface. The only fibers which are derived from the lateral surface are those from the periosteum. This fact is of considerable importance in reconstructive surgery of the ankle joint, since strong ligamentary insertions which surround the lateral surface of the fibula necessarily oppose rotation or screw-like movement of the fibula about its longitudinal axis.

[Planning of a complex intertrochanteric osteotomy (author's transl)]

The article describes in detail the preoperative planning on a complex intertrochenteric osteotomy with eight corrections. Attention is drawn to two main complication risks and how to avoid them, namely, necrosis of the head of the femur and tilting of the proximal fragment when inserting the blade of the rectangular plate.