Clinical outcomes of Epstein-Barr virus (EBV)-associated metastatic and locally advanced unresectable gastric cancers (GCs) in patients receiving first-line fluoropyrimidine and platinum (FP) doublet chemotherapy

BACKGROUND

Epstein-Barr virus-associated gastric cancer (EBVaGC) is a distinct molecular subgroup showing excellent outcomes after surgery for localized disease. Prominent immune cell infiltration in EBVaGC reflects the immunogenicity of Epstein-Barr virus (EBV) and, as suggested by some investigators, responsiveness to immune checkpoint inhibitors in the palliative setting. However, few data are available on the prevalence, clinical characteristics, and prognosis of EBVaGC patients receiving palliative cytotoxic chemotherapy.

METHODS

In this retrospective study, we identified 1061 patients with metastatic, recurrent, or locally advanced unresectable gastric cancer (GC) who started first-line fluoropyrimidine/platinum (FP) doublet chemotherapy with or without trastuzumab from January 2015 to August 2018. For 766 patients with available tumor tissue, the presence of EBV in cancer cells was evaluated by EBV-encoded RNA in situ hybridization and correlated with clinical characteristics and treatment outcomes.

RESULTS

Among the patients evaluated (n = 766), 40 (5.0%) were EBV-positive. EBVaGC was associated with male sex (p = 0.009) and lower neutrophil-lymphocyte ratio (NLR < 2.46, p = 0.03). Efficacy of first-line FP chemotherapy, in terms of response rate ad progression-free survival (PFS), did not differ between EBVaGC and EBV-negative GC (overall response rate: 53.8% vs. 51.8%, p = 0.99; median PFS: 6.4 vs. 6.7 months, p = 0.90). However, overall survival tended to be better with EBVaGC than EBV-negative GC (16.4 vs. 14.0 months, p = 0.07).

CONCLUSIONS

EBVaGC accounted for 5% of metastatic/unresectable GCs. While EBVaGC was not associated with better response to or PFS following first-line cytotoxic chemotherapy, it showed a trend toward better overall survival.

Microbial contamination of tattoo and permanent makeup inks marketed in the US: a follow-up study

In a 2018 survey, U.S. Food and Drug Administration (FDA) identified microbial contamination in 42 (49%) of 85 unopened tattoo and permanent makeup (PMU) inks purchased from 13 manufacturers in the US between November 2015 and April 2016. To confirm the results of our previous survey, we evaluated the level of microbial contamination in an additional 27 samples from 10 manufacturers from September 2017 to December 2017, including 21 unopened tattoo and PMU inks which were selected based on our previous survey results and 6 ink diluents that were not previously analysed. Aerobic plate count and enrichment culture methods from the FDA's Bacteriological Analytical Manual revealed 11 (52%) out of 21 inks, from six manufacturers, were contaminated with micro-organisms, with contamination levels up to 3·6 × 10⁸  CFU per gram, consistent with our previous survey results. We identified 25 bacterial strains belonging to nine genera and 19 species. Strains of Bacillus sp. (11 strains, 44%) were dominant, followed by Paenibacillus sp. (5 strains, 20%). Clinically relevant strains, such as Kocuria rhizophila and Oligella ureolytica, were also identified, as similar to the findings in our previous survey. No microbial contamination was detected in any of the six ink diluents.

Morphological adaptation of the bone graft and fused bodies after non-instrumented anterior interbody fusion of the lower cervical spine

PURPOSE

To assess the remodelling process of the bone graft and fused bodies after non-instrumented anterior interbody fusion with autogenous iliac graft in patients with spondylosis, infections, fractures, or disorders of the cervical spine.

METHODS

68 patients aged 18 to 58 years who underwent non-plated anterior lower cervical interbody fusion with an iliac graft were retrospectively studied. Diagnoses of the patients were degenerative disc diseases (n=32), disc herniation (n=15), fractures (n=13), and tuberculosis (n=8). The Robinson and Smith technique was used to treat degenerative disc diseases and protruded disc, and the Bailey and Badgley procedure for fractures or tuberculosis of the cervical spine. 34, 25, and 9 patients underwent one-, 2-, and 3-segment fusions, respectively. 18 of the 25 patients underwent two-segment fusion with a single large bone block, and 7 with 2 separate bone blocks for each segment. Four of the 9 patients underwent three-segment fusion with a single large bone block, and 5 used separate grafts for each segment independently. Plain and stress radiography was primarily used to assess the fusion. Computed tomography and magnetic resonance imaging were also used in some patients. Some anterior graft extrusion (amounting to less than 10% of corresponding anteroposterior body width) was used to observe the remodelling during graft-take and thereafter. Postoperative cervical traction for 2 to 4 weeks, then cervical collar immobilisation for 4 to 12 weeks were strictly followed according to the numbers of fused segments. A halo vest was applied in 4 patients with fracture undergoing 3-segment fusion as they could not tolerate the prolonged bed rest or rigid cervical brace.

RESULTS

The mean time for the graft to fuse was 8.6 (range, 7-14) weeks in patients who underwent each segment fusion with independent free grafts, and 10 and 14 weeks in those who underwent 2- and 3-segment single large graft fusion, respectively. The final loss of disc height and joint angle were negligible, regardless of the extent of fusion. Bony absorption of the anteriorly protruded part of the graft began at postoperative week 10 (range, 6-28), which coincided with the time of graft-take and initiation of remodelling.

CONCLUSION

The earliest sign of bony absorption of the anteriorly protruded part of the graft indicated the initiation of the graft-take and the graft remodelling. The inwaisting sign of the surgically fused block of vertebral bodies was a morphological adaptation. Despite the altered biomechanics of the spine in the fused area, the inwaisting sign indicated maintenance of normal function at the parafusion motion segments.

Resistance to adefovir dipivoxil in lamivudine resistant chronic hepatitis B patients treated with adefovir dipivoxil

BACKGROUND

Adefovir dipivoxil (ADV) is a potent nucleotide analogue against both the wild-type and lamivudine (LMV) resistant hepatitis B virus (HBV). The cumulative incidence of ADV resistant mutations in the nucleoside/-tide treatment naive chronic hepatitis B patient (CHB) at weeks 48, 96, and 144 was 0, 0.8-3%, and approximately 5.9%, respectively.

AIMS

The aim of this study was to characterise the genotypic and phenotypic mutation profiles to ADV in 67 LMV resistant CHB patients who were treated with ADV.

METHODS

Serum HBV DNA was quantified by real time polymerase chain reaction. The ADV mutant was detected using matrix assisted laser desorption/ionisation time of flight mass spectrometry based genotyping assays, termed restriction fragment mass polymorphism (RFMP).

RESULTS

RFMP analysis revealed that a total of 11 amino acid substitutions developed in the rt domain of the HBV polymerase in nine patients. The cumulative incidence of genotypic ADV resistance at months 12 and 24 was 6.4% and 25.4%, respectively. The rtA181V, rtN236T, and rtA181T mutations were detected in five, four, and two of the 67 patients at treatment months 12-17, 3-19, and 7-20, respectively. Serial quantification of serum HBV DNA revealed that two patients with the rtA181V mutation, with or without the rtN236T mutation, and one patient with the rtA181T mutation displayed HBV DNA rebound.

CONCLUSION

Emergence of the ADV mutation in LMV resistant patients who are treated with ADV appeared to present earlier and more frequently than was reported in previous studies on nucleoside/-tide treatment naive patients.

Polyamine depletion partially reduces the radiation-induced cell death via cell cycle delay mediated by thioredoxin

In previous studies, polyamine depletion by DFMO (alpha-difluoromethylornithine)-treatment reduced H(2)O(2)-induced apoptotic cell death by reduction of ferric ion uptake. In the present study, we analyzed the reduction of radiation-induced cell death by polyamine depletion. Exposure of HT29 cells to radiation induced severe cell death, but when cells were pretreated with DFMO, a specific inhibitor of polyamine biosynthesis, radiation-induced cell death was reduced to 50-60% of control. Cell cycle analysis showed that, in these cells, the time to reach the G(2)/M phase arrest was delayed for 20-24 h compared to the control cells, at which stage the fate of cells exposed to ionizing radiation is determined. DFMO-treated cells also showed a low level of thioredoxin, which is a high-level determinant of the cellular fate. To investigate the relationship between the G(2)/M phase arrest and the reduction of thioredoxin caused by polyamine depletion, we also analyzed thioredoxin-antisensed (asTRX) HT29 cells as for DFMO-treated cells. In asTRX-transfected cells, the gamma-irradiation-induced G(2)/M phase arrest was also significantly delayed and radiation-induced cell death was profoundly reduced, as in the DFMO-treated cells. Both sets of cells showed a decrease of cyclin D1 and an increment of HSP25, which are involved in radiation-induced cell cycle progress. Overall, these results suggest that polyamines are essential for normal cell death of HT29 cells triggered by gamma-radiation and that this is partially mediated by the regulation of thioredoxin expression.

Alpha-difluoromethylornithine, ornithine decarboxylase inhibitor, antagonizes H2O2-induced cytotoxicity in HL-60 leukemia cells: regulation of iron-dependent lysosomal damage

Recent studies indicate that reactive oxygen species, such as H2O2, can be generated by anti-cancer drugs, can damage cells, and then induce apoptotic cell death. In this study, we reported whether polyamines were capable of affecting apoptotic cell death triggered by H2O2 in leukemia cells or not. Alpha-difluoromethylornithine treatment (DFMO, 3 mmol/L, 48 h), which depletes intracellular putrescine by inhibiting ornithine decarboxylase, reduced H2O2-induced cell death in the HL-60 leukemia cells. Cytotoxicity caused by H2O2 in putrescine-depleted cells was 50% lower than that in the control cells, as determined by propidium iodide, the annexin V and DNA fragmentation assays. Following putrescine (1 mmol/L) supplement, cell death induction caused by H2O2 was restored to a similar level as the DFMO-untreated control cells. It seems that this partly resulted from the intralysosomal iron-dependent oxidation of the cells because DFMO did not significantly affect the increment of enzymes related to oxidative-stress resistance. Putrescine depletion by DFMO treatment reduced the cellular iron uptake of the cells by about 70%. In parallel to the reduction of iron uptake, lysosomal damage (assayed by acridine orange relocalization or uptake test) in the DFMO-treated cells was far less than that in the control cells. Moreover, putrescine supplement also restored the iron uptake to the control cell levels. Pre-incubation with desferrioxamine (DFO), which chelates iron and forms a non-reactive Fe-DFO complex that is localized in the lysosomal compartment, inhibited H2O2-induced cell death. This work suggests that polyamines may play a critical role in apoptotic cell death triggered by H2O2 via the regulation of the iron-dependent instability of the lysosome.

Stabilisation of fractured thoracic and lumbar spine with Cotrel-Dubousset instrument

OBJECTIVE

To evaluate the effectiveness of 2 different types of Cotrel-Dubousset instrument systems in stabilising thoracolumbar and lumbar spine fractures.

METHODS

Between January 1989 and December 1993, 45 fractures in 42 patients with unstable fracture or fracture dislocation of the thoracolumbar and lumbar spines were randomly assigned to 2 surgical treatments with Cotrel-Dubousset instrumentation-using either a long segment (Group 1) or a short segment (Group 2)-and short posterolateral fusion.

RESULTS

Consolidation of the fractured vertebral body and posterolateral fusion were achieved at a mean time of 4.5 months; fusion rates were 75% in Group 1 and 83% in Group 2. The average collapses of anterior vertebral body height in Group 1, in the immediate postoperative period and at the final follow-up, were 15% and 17%, respectively; and in Group 2, the figures were 16% and 24%, respectively. The correction of vertebral height and kyphosis at the last follow-up were lost more in Group 2 (5.7 degrees ) than in Group 1 (4.4 degrees ). There were neurological recoveries in 6 of the 9 cases of incomplete paraplegics, including complete recovery in 5, and one-Frankel grade increase in one. There were 15 instrument failures in 12 patients, including screw breakage in 3 Group 1 cases and 6 Group 2 cases. The plug dislodged in 3 Group 1 cases, and the hook dislodged in 3 Group 2 cases. In other words, instrument failures were more common in Group 2.

CONCLUSION

Cotrel-Dubousset stabilisation of the fractured spine achieves fracture consolidation, but does not maintain the restored height and sagittal curve completely until fusion. The long rod and short fusion construct was more effective for all fracture types than was the short rod and fusion construct, although it leads to wider immobilisation of normal segments.

Brooks' posterior stabilisation surgery for atlantoaxial instability: review of 54 cases

PURPOSE

To assess the effectiveness of Brooks' posterior stabilisation and fusion for the unstable atlantoaxial joint due to congenital dysplastic dens and trauma.

METHODS

We retrospectively studied records of 54 patients (36 males and 18 females; age range, 3-58 years) who underwent Brooks' posterior stabilisation procedure between March 1975 and December 1999, at the Catholic University of Korea Medical Center and Dong-Shin General Hospital, Seoul. A single-stranded Kirschner wire was used to stabilise the first 19 cases (thin wires in 12 cases and thick wires in 7), and double-stranded wires were used in the next 35 cases (thin wires in 4 cases and thick wires in 31). After surgery, patients were immobilised in bed with light Halter traction of the head, followed by cervical bracing.

RESULTS

Fusion was observed by X-ray postoperatively at 15 weeks in 48 patients. Reduction was achieved in 3 luxation cases (including the single case of rotatory fixation). Brooks' fusion failed in 4 patients with dens fractures and 2 with dens anomaly. Four dens fractures in cases of successful Brooks' fusion in Brooks' fusion did not unite. Wire failure occurred in 4 cases of thin single-stranded wire fixation, namely, 2 cases of dens fractures and 2 of dens anomaly.

CONCLUSION

Brooks' procedure is safe and has a high fusion rate when double-stranded strong wire fixation of the atlantoaxial joint is combined with meticulous bone grafting and subsequent cervical bracing.

Traumatic spondylolisthesis of the axis: 42 cases

Fourty-two patients (34 males and 8 female) with traumatic spondylolisthesis of the axis were studied in a retrospective review There were 20 stable and 22 unstable fractures. The 22 unstable fractures were treated surgically: 16 anterior interbody fusion (10 non-plated and 6 plated), 4 pedicle screw fixation for osteosynthesis of the fractured pedicles, and 2 posterior wire fixation for flexion and axial load injury. For all non-surgical cases, head halter tractions for 1 to 8 weeks was prescribed and a cervical orthosis was worn for an additional 6 to 18 weeks. The surgical cases underwent 5 to 7 days of preoperative and 1 to 4 weeks of post-operative head halter traction. In all cases pedicle fractures united after 13 weeks on average in group treated conservatively, 12 weeks (11 to 13 weeks) in the posterior wiring group, 8 weeks (7 to 9 weeks) in the group in which pedicle screws were used, and 11 weeks (9 to 15 weeks) in the anterior fusion group (13 weeks in non-plated, and 8 weeks in plated). There were no differences in patterns of anterior fusion between those in the non-plated and plated groups. There were no non-unions of fractured pedicles and there was no late instability of the C2-C3 or neurological complications. In 2 cases in the posterior surgery group, there was mild nuchal discomfort and some rigidity for a short while postoperatively. Final outcomes were good in all cases.

Effect of BPV1 E2-mediated inhibition of E6/E7 expression in HPV16-positive cervical carcinoma cells

OBJECTIVE

E6 and E7 proteins of high-risk-type human papillomavirus are major etiological agents for cervical carcinomas and are continuously expressed in those cancer cells. They inhibit cell cycle control functions by inactivating p53 and Rb proteins and also immortalize cells through the induction of telomerase activity. Expression of E6 and E7 genes in HeLa, an HPV18-positive cell line, has been shown to be inhibited by the E2 protein of bovine papillomavirus (BPV1), and this resulted in the activation of the p53-mediated growth inhibitory pathway followed by an inhibition of cell proliferation. In this study, the effect of BPV1 E2-mediated inhibition of E6 and E7 expression was examined in HPV16-positive cervical carcinoma cell lines recently established from Korean patients.

METHODS

BPV1 E2 was expressed in the test cells through acute infection of an SV40-BPV1 recombinant virus. Its effect on cell proliferation was assessed through MTT and DNA synthesis assays, and the status of factors involved in cell cycle control was examined through Western blotting and reverse transcription-polymerase chain reaction.

RESULTS

BPV1 E2 expression caused a significant decrease in E6/E7 transcription in all three cell lines. This was accompanied by an increase in the levels of p53 protein and activity and a decrease in the expression of Cdc25A, a Cdk2-activating phosphatase. Concomitantly, E2F1 activity and cellular DNA synthesis capacity were significantly reduced.

CONCLUSIONS

These results indicate that inhibition of E6/E7 gene expression in the HPV16-positive cervical carcinoma cells induces suppression in cell proliferation by activating the growth inhibitory factors, p53 and Rb, and also by downregulating the cell cycle stimulatory factor, Cdc25A.

Fate of the facet joints after instrumented intertransverse process fusion

A success or failure of an intertransverse process fusion has been determined by the fusion status of the intertransverse fusion mass alone, and little consideration has been given to the fusion status of the facet joint. The purpose of this study was to assess the fusion status of the facet joints at the fusion level and its impact on the overall fusion outcome. Sixteen patients (19 levels) treated with decompression and intertransverse process fusion using pedicle screw fixation without facet arthrodesis were entered into a cross sectional study in which the fusion status of the intertransverse fusion masses and facet joints at each fusion level were evaluated and combined at an average duration of followup of 35 months (range, 22-61 months). Union rate of the intertransverse process fusion (58%, 22 of 38) was lower than the spontaneous fusion rate of the facet joint (68%, 26 of 38). However, the combination of the two fusion statuses at each fusion level generated 89% of the overall fusion rate (17 of 19 levels). With surgery, all patients had a good or excellent clinical outcome, but the outcome had no relation to the overall fusion status. The results suggest that the fusion status of the facet joint should be considered in determining overall fusion status after combined decompression with instrumented intertransverse process fusion.

Analysis of cDNAs expressed during first cell division of petunia petal protoplast cultures using expressed sequence tags

A large-scale sequence analysis of randomly selected cDNA clones was performed to isolate numerous genes in petunia petal protoplast cultures. We have partially sequenced 1158 randomly selected genes of the cDNA library constructed from 2-6 d cultured petal protoplasts. Three hundred and sixty-five different genes were identified, 25% of which showed significant similarity to existing sequences in the petunia, and an array of other organisms. In this report, 90 independent genes are analyzed in detail. A functional categorization of the database-matched expressed sequence tags (ESTs) showed that defense- or stress-related genes, as well as genes involved in the primary metabolic pathways and in the transcriptional or translational apparatus are abundantly represented. In particular, ESTs were identified with apparent homologies to the cyclin-dependent kinase, histone, actin-depolymerizing factor, proteasome, and ubiquitin which are expected to be related to cell division or to cell cycle control.

Volumetric change of the graft bone after intertransverse fusion

STUDY DESIGN

Patients in whom good intertransverse fusion had been achieved were selected for the volumetric study of the fusion mass using sequential computed tomography scans.

OBJECTIVES

To assess the natural volumetric change of intertransverse fusion mass and the effect of the disease entity and spinal instrumentation on the fusion mass volume.

SUMMARY OF BACKGROUND DATA

The magnitude of volumetric change of the graft bone after intertransverse fusion is still inconclusive.

METHODS

Fifteen adult patients who underwent decompression surgery with single-level lumbar and lumbosacral intertransverse fusion were selected for this study. Preoperative diagnoses were degenerative spondylolisthesis in nine patients and isthmic spondylolisthesis in six. Seven of the 15 patients received pedicle screw fixation. They were categorized into two major groups: 1) instrumented and noninstrumented groups and 2) isthmic and degenerative groups. To assess the volumetric change of the graft bone, sequential computed tomography scans were obtained 2 weeks after surgery and again 18 months after surgery.

RESULTS

The overall initial mean graft volume was 6251 mm3, which decreased to 2842 mm3 by 18 months after surgery (P < 0.001). The overall mean volume loss between the two periods was 54.8% of the initial graft volume. Although there was no significant difference in the mean graft volume between the groups at either 2 weeks or 18 months after surgery (P > 0.05 in all comparisons), the mean graft volume in each group decreased significantly during the observation period (P < 0.01 in all comparisons). There was no significant difference in the mean volume loss or in the ratio of residual volume to the initial graft volume between the groups during the study period (P > 0.05 in all comparisons). The initial graft volume correlated positively with the graft volume at 18 months after surgery (r = 0.612, P < 0.01) and volume loss (r = 0.949, P < 0.01), but negatively with the residual volume ratio (r = -0.507, P < 0.01).

CONCLUSIONS

These results showed that more than one half of the initial graft bone volume was being absorbed during the consolidation processes of the graft bone, and that the volume loss during the period was not significantly affected by the spinal instrumentation or by the disease entity. It was also found that the greater the amount of the initial graft bone, the larger the fusion mass at 18 months after surgery. The volume loss, however, increased proportionally to an increase in the initial graft bone volume. The efficiency (ratio of residual volume to the initial graft volume) of the intertransverse fusion also tended to decline as the initial graft volume increased.

Valgus ankle secondary to acquired fibular pseudoarthrosis in children. Long-term results of the Langenskiöld operation

Nine cases of acquired absence of the fibular shaft were studied to determine the growth contribution of the distal fibula; in 6 cases the absence was caused by osteomyelitis and in 3 cases by trauma. The average valgus and external rotational deformities were 15.2 degrees and 10 degrees, respectively. In 3 of 7 cases surgically treated with Langenskiöld operation or supramalleolar corrective osteotomy, the valgus deformity recurred during the postoperative growth period. The speculated causes of gradual valgus deformity are the loss of physiologic thrust from the proximal to distal fibula, the tethering effect of contracted soft tissue on distal fibula and early physeal closure of the lateral part of the distal tibia due to continuous, uneven axial overloading. The Langenskiöld operation was found effective for the stability of ankle joint in the initial period, but could not prevent the postoperative revascularization of the ankle. However, it is strongly recommended that any types of prophylactic surgery should be carried out before the development of an epiphyseal deformity of distal tibia, and to prevent secondary osteoarthritis of the ankle joint.

Collagen fibres and mechanoreceptors in regenerated menisci of rabbits

Total medial meniscectomy was carried out on 30 mature rabbits; subsequent regeneration of the meniscus and degenerative joint changes were observed. Out of 30 knees, 22 had regenerated menisci and 10 of these had not developed gross degenerative changes after 6 months. Collagen fibres were arranged irregularly in the regenerated menisci, although in some areas they occurred in parallel. Every type of mechanoreceptor was found in the outer third of the normal menisci, and in the middle and outer third of the regenerated menisci with no statistical difference in numbers. Mechanoreceptors can regenerate in regenerated menisci and may protect the join from degeneration.

Tuberculosis of the spine. Controversies and a new challenge

Tuberculosis is a deadly disease affecting many people in the world. The prevalence of spinal tuberculosis is likely to rise as the numbers of those infected with human immunodeficiency virus rises. This presentation summarizes present knowledge of spinal tuberculosis and its management. It describes and updates material the author has previously published on this subject. The scientific basis for the clinical management of spinal tuberculosis has been well established by the British Medical Research Council group and Hong Kong surgeons. It is believed, however, that well-controlled basic and clinical studies are required if the incidence of the three unwanted complications of spinal tuberculosis is to be reduced further. Antituberculosis agents are the mainstay of management, with chemotherapy for 12 months preferred to shorter courses. The standard is a combination of isoniazid, rifampin, and pyrazinamide, with or without ethambutol. Anterior surgery consisting of radical focal debridement without fusion does not prevent vertebral collapse. The major advantage of anterior arthrodesis is the decreased tendency for progression of the deformity. Patients who present late with deformity are candidates for anterior debridement and stabilization with corrective instrumentation. Posterior stabilization with instrumentation has been found to help arrest the disease and to bring about early fusion. Posterior instrumented stabilization to prevent kyphosis in early spinal tuberculosis is indicated, however, only when anterior and posterior elements of the spine are involved, particularly in children. With early detection, institution of chemotherapy, and improved surgical techniques, patients with kyphosis rarely are seen today, particularly in urban centers that have an effective medical system. For these same reasons, patients with spinal tuberculosis who present with paraplegia and no deformity usually respond well to treatment. It is concluded that spinal tuberculosis without unsightly kyphosis and neurologic symptoms is a medical, rather than a surgical, condition. Surgery should be reserved for those patients who have advanced tuberculosis with unacceptable complications such as paraplegia and/or deformity.

Varus and internal rotational deformity of the ankle secondary to distal tibial physeal injury

Nine children who sustained Lauge-Hansen's supination-inversion injury of distal tibial physeal injury with intact distal fibular physis, were followed until their maturity. The average varus deformity was 39 degrees (maximum, 80 degrees) with 23 degrees of internal rotational deformity. The longitudinal growth of the fibula was retarded compared with opposite normal leg. There was early closure of the medial distal tibial physis, gradual upward migration of medial malleolus, and eventually medial subluxation of the ankle; these resulted in gradual varus and internal rotational deformities of the injured ankle. It is thought that the resultant disabling deformity of ankle should be prevented by any means, though presently there are no available effective methods of treatment. It is suggested that the repeated corrective osteotomy should be carried out before epiphyseal deformity of the distal tibia and subluxation of the ankle joint develop.

Habitual voluntary dislocation of the hip in a child. A case report

A child, 5 years of age, with habitual voluntary dislocation of the hip is reported. He was treated by an intertrochanteric osteotomy and made a satisfactory recovery.

Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines

STUDY DESIGN

Thirty-nine adults and five children with active spinal tuberculosis and resulting kyphosis of the dorsal and lumbar spine who had combined posterior instrumentation and anterior interbody fusion were observed to determine whether the corrected spinal deformity could be maintained until solid fusion.

OBJECTIVE

To evaluate the effectiveness of the combined two-stage procedure for treating kyphosis due to active spinal tuberculosis.

SUMMARY OF BACKGROUND DATA

Until 1970, with all methods of treatment, kyphosis due to active spinal tuberculosis tended to increase during therapy. Most of the patients treated with these methods were not happy with this residual kyphosis, even though their disease was arrested or cured. Kyphosis became their main concern regarding further treatment.

METHODS

A combined two-stage procedure, under the cover of 18 months of triple chemotherapy, was used for all patients. For posterior stabilization, the Harrington distraction system, Rush nails or Steinmann pins and wires, and Texas Scottish Rite Hospital instrumentation were used. The diagnosis of successful interbody fusion was made if there was no loss of correction, no graft resorption or graft bed resorption, and if there was visible graft remodeling, such as trabeculation between the graft beds and graft and the graft hypertrophy.

RESULTS

In the 39 adults, average preoperative, immediate postoperative, and last follow-up kyphosis angles were 37 degrees, 16 degrees, and 18 degrees, respectively. In four children, the average preoperative, immediate postoperative, and last follow-up kyphosis angles were 55 degrees, 28 degrees, and 31 degrees, respectively. The loss of correction did not exceed 3 degrees. For one-segment spondylodesis, the average fusion times were 4 months in adults and 3.5 months in children. For a two-segment fusion, the average fusion times were 6 months in adults and 6.3 months in children.

CONCLUSION

Posterior instrumental stabilization and anterior interbody fusion were found helpful in arresting the disease early, providing early fusion, preventing progression of kyphosis, and correcting the kyphosis.

Squatting following total knee arthroplasty

This prospective study was performed to investigate whether postoperative alternate flexion and extension splinting (daily change in position of immobilization by splinting) was useful in restoring full range of motion (ROM) after total knee arthroplasty as compared with continuous passive motion. The alternate flexion and extension splinting group and the continuous passive motion group were each composed of 34 knees. Final ROM was measured at an average of 3.5 years postoperatively. Squatting was possible in 31 knees (45.6%) of the alternate flexion and extension splinting group. The postoperative ROM of the osteoarthritic knees (131.8 degrees +/- 12.3 degrees) was significantly greater than that of the rheumatoid knees (121.9 degrees +/- 22.4 degrees) (p < 0.05). The postoperative ROM of the alternate flexion and extension splinting group (135.1 degrees +/- 11.9 degrees) also was significantly greater than that of the continuous passive motion group (120.0 degrees +/- 19.7 degrees) (p < 0.01). There was no statistically significant relationship between the posterior slope of tibial cutting and the postoperative ROM. It is suggested that alternate flexion and extension splinting is effective in restoring full ROM after total knee arthroplasty.

Anterior spondylodesis for spondylolisthesis: isthmic and degenerative types

We studied the influence of instability of the spondylolisthetic segment upon anterior interbody fusion (AIF) rates. A one-level AIF of the lumbar spine by the modified extraperitoneal Bailey-Badgley fusion construct was performed in 26 patients with chronic or recurring acute low-back pain and/or other symptoms due to grades I and II spondylolisthesis. Sixteen were degenerative type, and 10 were isthmic type. Seventeen were female and 9, male. The average age was 41.2 years. The number of cases of spondylolisthesis at the level of L4-5 and L5-S1 as 18 and 8, respectively. In the 16 cases of degenerative type, 13 were grade I slip, and 3 were grade II slip, while in the 10 cases of isthmic type, 8 were grade I slip, and 2 were grade II slip. The average postoperative follow-up was 6 years (range 2-10 years). Solid fusion was obtained in 15 (93.8%) of the cases of degenerative spondylolisthesis and in 6 of the cases of isthmic type. Thus, the overall fusion rate was 80.7% (21 cases). However, some graft crumbling and redisplacement developed in 1 of the cases of degenerative type and 6 of the cases of isthmic type. Non-union developed in 4 (57.1%) of those 7 cases of graft crumbling (3 isthmic and 1 degenerative type). Fusion took 7 months on average (range 5-9 months). It is hypothesised that the isthmic-type spondylolisthesis had more instability than the degenerative one. Therefore, AIF in the case of degenerative spondylolisthesis is a useful procedure, while in the isthmic type it is not advisable as a routine procedure.

The effect of multilevel laminectomy on the cervical spine of growing cats. An experimental study

This experiment was undertaken to observe the effect of multilevel laminectomy on the cervical spine of growing cats. Wide cervical laminectomy was done from C3 to C6 on 24 immature cats and 24 mature cats. Cervical kyphosis gradually developed in the growing cats postoperatively after 4 months; normal cervical curves were maintained in the mature cats. Corporal subluxation at the kyphotic segment was detected postoperatively after 4 months, but the characteristic wedge-shaped deformity of the vertebral body of the swan-neck deformity was not detected using serial radiographs during the 12-month observation period. Histologically, there was no evidence of thinning or early fusion of the anterior part of the physis throughout the observation period. Post-laminectomy kyphosis developed as the result of forward subluxation of vertebral bodies because of the destabilizing surgery.

Tuberculosis of the ischiopubic ramus. A report of five cases

Five cases of tuberculosis of the ischiopubic ramus are reported. All presented with abscesses. Treatment by simple curettage and INH, rifampicin and ethambutol given for 18 to 24 months gave satisfactory results in the 4 patients who were children. The one adult had severe disruption of the symphysis pubis, and sacroiliac involvement; a good result was obtained after bone grafting and fixation with a plate.

The response of nerve tissue to chymopapain

This study was undertaken to clarify the effects of topically injected chymopapain on the spinal cord and peripheral nerves in rabbits, and also the effect of ganglioside on sciatic nerves which had been damaged by chymopapain. There were no abnormal macroscopic or microscopic findings when chymopapain was injected around the sciatic nerve sheath or around the spinal dura mater, but when it was injected directly into the nerve sheath there was immediate paralysis and severe axonal necrosis; the Schwann sheath remained intact and there was haemorrhage. Injection into the dura resulted in massive haemorrhage, perivascular neutrophil infiltration and necrosis of grey matter. In those treated with ganglioside, regeneration of the damaged sciatic nerve was shorter than in those not so treated.

Degenerative changes after meniscectomy and meniscal regeneration

In an experimental study on rabbit knees, regeneration of the medial meniscus occurred following 9 out of 10 meniscectomies, compared with only 1 out of 10 lateral menisci. Degenerative changes in the articular cartilage were seen in 8 of 9 knees where the lateral cartilage failed to regenerate, but in only 2 of 9 with a regenerated medial cartilage. The rate of regeneration is lower after lateral meniscectomy and this may partially explain the occurrence of more severe degenerative changes after this operation.

Meniscal regeneration and its effects on articular cartilage in rabbit knees

The incidence and size of meniscal regeneration after medial meniscectomy on the right knee and lateral meniscectomy on the left knee of 44 rabbits was observed and correlated with development of degenerative arthritis. Complete meniscal regeneration was found in 23% of medial meniscectomy knees, partial regeneration in 68%, and no regeneration in 9%. Among 44 lateral meniscectomies, only 5% had complete meniscal regeneration, and 68% had no meniscal regeneration. The remaining 27% of knees had partial regeneration. Degenerative changes of articular cartilage in the tibiofemoral joints of all knees were inversely correlated with the size of the regenerated meniscus. These observations suggest that poor results following lateral meniscectomy may be due to a lower level of meniscal regeneration and relatively poor morphological regeneration of the lateral meniscus compared to the medial meniscus.

Conservative treatment of tuberculosis of the thoracic and lumbar spine in adults and children

We have treated 75 cases of spinal tuberculosis with chemotherapy as outpatients. The drugs used were INH, rifampicin and ethambutol for the 48 adults, and INH, rifampicin and PAS for the 27 children. No operations, apart from the evacuation of large abscesses, were carried out. Every patient was followed up for at least three years and the outcome was judged to be favourable in 95%. This is better than in some series in which radical surgery has been used. Although we recognize the advantages of operation in certain circumstances, we believe that our conservative regimen can be confidently recommended for use in less privileged countries, where adequate facilities for hospital treatment may not be available.

The healing of femoral neck fractures in dogs. The use of intraosseous venography and India ink staining

This study evaluates healing fractures of the femoral neck in dogs by using standard radiography, intraosseous venography, India ink staining and histology. The 45 animals were divided into three groups, one of which was not treated, but in the other two the fracture was fixed with a screw or two Kirschner wires. Our results suggest that, when intraosseous venography was positive India ink injection was also positive, and the late phase of fracture healing was reached.

The effect of posterior spinal fixation with acrylic cement on the vertebral growth plate and intervertebral disc in dogs

We have attempted to clarify the serial histological changes in the growing spine of dogs following posterior fixation with acrylic cement. Twenty-four male mongrel dogs aged 8 weeks were used for the study. The lumbar spine from L.3 to L.5 was fixed posteriorly with acrylic cement. Three dogs were then sacrificed every four weeks up to 32 weeks, and the histological changes of the vertebral disc, growth plate and vertebral bodies were observed by light microscopy. Thinning of the growth plate and distortion of the cartilage columns has been demonstrated, but premature fusion of the growth plate did not result and vertebral body growth continued. Anterior wedging of the intervertebral disc was seen with some thinning of the bony trabeculae of the vertebral body. Degeneration of the nucleus pulposus resulted, with replacement by fibrous tissue. The normal horizontal arrangement of the fibres of the annulus fibrosus altered to a vertical configuration by 32 weeks.

The effect of synovectomy on the articular cartilage of the knee joint in rabbits

Subtotal synovectomy was performed on the right knee joints of 20 immature and 20 mature rabbits, and articular cartilage from the femoral and tibial condyles and the patellae was examined at 1, 3, 5 and 12 weeks after operation. Specimens from the unoperated left knees provided the controls. Each specimen was examined macroscopically and with histological (H-E stain) and histochemical (safranin-O stain) techniques for abnormalities in structure, cell population, stain intensity and distribution. The femoral articular cartilage was most affected by synovectomy. The tibial articular cartilage was only moderately affected and the patellar articular cartilage was even less affected. The histochemical changes were transient and reversible, being more severe and prolonged in the mature animals. No changes in either group were noted on gross inspection or in the H-E stained sections.

A natural course of a dislocated healed tuberculous hip in a child. A case report

Subluxation was once a common complication of the tuberculous hip, even when properly treated. A review of the English literature failed to disclose the corrective process of development of the hip joint following a debridement operation. A three-year-old boy having a proven tuberculous hip had his hip dislocated after joint debridement. In the ensuing ten years, the luxated head spontaneously reduced to nearly normal position. Transitory capsular laxity was believed to cause the dislocation in this case, while growth and development led to spontaneous reduction. A decade may elapse before relocation is complete.

The normal and regenerated meniscus in rabbits. Morphologic and histologic studies

The chronologic development of normal and regenerated menisci in immature and adult rabbits, studied by gross, histologic, and histochemical means, revealed that grossly regenerated menisci were less glossy and smaller than normal, with blunt margins and firm attachments to the synovial membrane. The normal meniscus of five-week-old rabbits consisted of fibroblasts and fibrocytes without cartilage cells. In 12-week-old rabbits fibrocytes in the normal meniscus had been transformed into round or oval cells lying within lacunae, the halos of which stained with safranin O. In the typical regenerated meniscus fibrocartilage cells appeared 12 weeks after meniscectomy in young rabbits and 24 weeks after meniscectomy in adult rabbits. Cartilaginous transformation occurred infrequently and only in isolated areas of the meniscus. Cartilaginous transformation in regenerated menisci appeared in 10.6% of the knees in young rabbits and in 8.1% in adult rabbits.

The influence of severity of angulatory deformity of rat's tibia on spontaneous correction

In order to estimate the spontaneous correctability of tibial deformity, retrocurvature of various degrees in the growing rat tibia was observed roentgenologically at 2 to 3 weekly intervals for eight week periods. The results obtained were: in the retrocurvated rat tibia of groups I, II and III, 11.1 +/- 2.6%, 7.2 +/- 1.7% and 7.4 +/- 1.1% respectively of initial base angle were corrected in observation periods of between 3 to 8 weeks and the correction obtained between 3 to 5 weeks in groups I, II and III were 4.2 +/- 1.3 degrees (65.5%), 4.3 +/- 1.5 degrees (64.2%) and 5.0 +/- 1.3 degrees (67.9%), and between 5 to 8 weeks were 2.2 +/- 0.6 degrees (34.4%), 2.4 +/- 0.5 degrees (35.8%) and 2.7 +/- 0.9 degrees (32.1%), respectively. This study confirms that spontaneous correctability of deformed rat tibia decreased when the deformity is severe, and, irrespective of the severity of initial deformity, more than half of the initial base angles were corrected in an early phase, and remainders later. This fact indicates that the physeal and diaphyseal remodelling process is affected to some degree by the severity of the deformity.

Anterior interbody fusion in fractures and fracture-dislocations of the spine

Twenty-five cases of unstable fractures and fracture-dislocations of the spine are reviewed. They were treated at the Catholic Medical College and Centre in a 3-year period, 1975 to 1978. 1. Eleven of the 25 patients were treated by anterior interbody fusion performed at 6 to 8 weeks from injury or initial surgery. 2. Eleven patients had neurological deficits, 3 with incomplete lesions and 8 with complete lesions. Open reduction and decompression laminectomies were performed on patients having neurological deficits prior to anterior interbody fusion. Two patients with incomplete paraplegia showed marked neurological recovery whilst one with complete paraplegia regained some sensation. 3. Solid clinical fusion was obtained in all but one patient within four months of interbody fusion. 4. Amongst the 18 patients with kyphosis at the time of admission 10 had a final improvement of their kyphosis ranging from 3 to 10 degrees (average 6 degrees). Three had no change and 5 demonstrated a mild increase of kyphosis (average 4 degrees). 5. Pain was relieved in 21 patients out of 25. The advantages of this technique include effective stabilization, prevention of late deformity and relatively early mobilization without internal fixation.

Synovial biopsy by Franklin--Silverman needle

Franklin-Silverman needles, commonly used for liver biopsies, were used for biopsy of synovia of 75 joints. The results indicate a higher percentage of success in obtaining pathologic specimens than with previously reported instruments. Complications were rare, with only milk transient hemarthrosis being found in 5 cases. For an accurate diagnosis, multiple specimens should be obtained since single specimens are too small to interpret histopathologically. Being simpler and safer, the Franklin-Silverman needle biopsy is recommended as a routine procedure for early diagnosis of synovial diseases of the joint in conjunction with joint aspiration. The success rate depends not only on the type of needle used but also on the proper selection of the biopsy site.

The influence of physeal injury upon growth correction of deformed rat tibia

Experimentally produced angulatory deformities of rat tibia with and without physeal injury were observed at two to three-week intervals for an eight-week period by x-ray studies, in order to estimate the spontaneous correctability of tibial deformity in growing rats. The results obtained were as follows: 1) In the retrocurvated rat tibia with intact physes or with distal physeal injury, roughly one quarter of the initial angle was corrected during the eight-week observation period, with greater correction occurring during the first five weeks in both groups. 2) Injury of the distal physis hardly influenced the correction capacity of the deformed tibia. 3) The physis and diaphysis played equally important roles in the remodelling process of rat tibia with intact physes. However, early remodelling took place on a considerably larger scale and with greater rapidity through physeal growth, and late remodelling similarly through the diaphyseal appositional growth.

The effect of posterior spinal fixation with bone cement upon vertebral growth in dogs. An experimental study

In an experimental study the authors tried to clarify the effect on vertebral growth and spinal curvature in dogs following fixation of the posterior elements of the spine at different levels using bone cement. In three separate experimental groups a segment of the dorsal spine, the dorso-lumbar spine or the lumbar spine was securely fixed with bone cement incorporating a radio-opaque wire marker. Growth of the spine was observed with renal X-rays over a six-month period and the following results obtained: 1. Growth in height of the vertebra was not affected by the fixation; 2. The intervertebral disc spaces widened anteriorly and narrowed posteriorly even when fracture of the bone cement occurred; 3. Increasing lordosis developed in all three experimental groups even when a physiological kyphosis was normally present. The greatest increase occurred in the lumbar spine; 4. Fracture of the cement occurred consistently when attempting to secure the dorso-lumbar junction.

Arm wrestler's injury: report of seven cases

Seven cases of fractures of the humerus from arm wrestling included 2 types of fractures. Two were spiral fractures of the humeral shaft with large butterfly fragments at the junction of the middle and distal one third caused by a violent uncoordinated muscular action. Five were fractures of the medial epicondyle of the humerus as a result of a sudden blow to the elbow. In all 7 cases, the fractures healed and arm function returned to normal.

Trochanteric intra-osseous venography in femoral neck fractures in the dog

This study of the healing of femoral neck fractures in dogs clearly indicates: 1. that the restoration of the intra-osseous flow through the fracture site occurs first followed by the appearance of venous drainage in the medial femoral circumflex vein and the vein of the ligamentum teres. 2. That if the intra-osseous flow is restored to the head through the fracture callus, normal fracture healing will proceed. 3. That avascular necrosis following a femoral neck fracture is also dependant on fracture union, and 4. that the incidence of traumatic avascular necrosis can be minimised by adquate fracture treatment. Thus accurate reduction and rigid immobilisation of the fracture promotes early formation of good endosteal callus and the restoration of intra-osseous venous blood flow and so early fracture union. The diagnosis of avascular necrosis of the femoral head may be established by measuring the clearance time of contrast medium flowing into the head via the crossing veins. If the contrast medium is cleared rapidly by the draining veins, it suggests that the head is viable.