Spinal osteosarcoma

Although osteosarcoma represents the second most common primary bone tumor, spinal involvement is rare, accounting for 3%–5% of all osteosarcomas. The most frequent symptom of osteosarcoma is pain, which appears in almost all patients, whereas more than 70% exhibit neurologic deficit. At a molecular level, it is a tumor of great genetic complexity and several genetic disorders have been associated with its appearance. Early diagnosis and careful surgical staging are the most important factors in accomplishing sufficient management. Even though overall prognosis remains poor, en-block tumor removal combined with adjuvant radiotherapy and chemotherapy is currently the treatment of choice. This paper outlines histopathological classification, epidemiology, diagnostic procedures, and current concepts of management of spinal osteosarcoma.

Dual lag screw cephalomedullary nail versus the classic sliding hip screw for the stabilization of intertrochanteric fractures. A prospective randomized study

This study is a randomized prospective study comparing two fracture fixation implants, the extramedullary sliding hip screw (SHS) and the dual lag screw cephalomedullary nail, in the treatment of intertrochanteric femoral fractures in the elderly. One hundred and sixty-five patients with low-energy intertrochanteric fractures, classified as AO/OTA 31A, were prospectively included during a 2-year period (2005-2006). Patients were randomized into two groups: group A included 79 hip fractures managed with sliding hip screws and group B included 86 fractures treated with cephalomedullary nails. Delay to surgery, duration of surgery, time of fluoroscopy, total hospital stay, implant-related complications, transfusion requirements, re-operation details, functional recovery, and mortality were recorded. The mean follow-up was 36 months (24-56 months). The mean surgical time was statistically significantly shorter and fluoroscopy time longer for the group B. No intraoperative femoral shaft fractures occurred. There was no statistically significant difference in the functional recovery score, reoperation, and mortality rates between the 2 groups. A new type of complication, the so-called Z-effect phenomenon, was noticed in the cephalomedullary nail group. There are no statistically significant differences between the two techniques in terms of type and rate of complications, functional outcome, reoperation and mortality rates when comparing the SHS and the cephalomedullary nail for low-energy AO/OTA 31A intertrochanteric fractures. Our data do not support recommendations for the use of one implant over the other.

Herpes virus infection can cause intervertebral disc degeneration

It has been proposed that intervertebral disc degeneration might be caused by low-grade infection. The purpose of the present study was to assess the incidence of herpes viruses in intervertebral disc specimens from patients with lumbar disc herniation. A polymerase chain reaction based assay was applied to screen for the DNA of eight different herpes viruses in 16 patients and two controls. DNA of at least one herpes virus was detected in 13 specimens (81.25%). Herpes Simplex Virus type-1 (HSV-1) was the most frequently detected virus (56.25%), followed by Cytomegalovirus (CMV) (37.5%). In two patients, co-infection by both HSV-1 and CMV was detected. All samples, including the control specimens, were negative for Herpes Simplex Virus type-2, Varicella Zoster Virus, Epstein Barr Virus, Human Herpes Viruses 6, 7 and 8. The absence of an acute infection was confirmed both at the serological and mRNA level.

To our knowledge this is the first unequivocal evidence of the presence of herpes virus DNA in intervertebral disc specimens of patients with lumbar disc herniation suggesting the potential role of herpes viruses as a contributing factor to the pathogenesis of degenerative disc disease.

Limb salvage after gas gangrene: a case report and review of the literature

Gas gangrene is a necrotic infection of soft tissue associated with high mortality, often necessitating amputation in order to control the infection. Herein we present a case of gas gangrene of the arm in an intravenous drug user with a history of intramuscular injections with normal saline in the shoulder used to provoke pain for recovery after drug induced coma. The patient was early treated with surgery and antibiotics rendering possible the preservation of the limb and some of its function. Additionally, a review of the literature regarding case reports of limb salvage after gas gangrene is presented.

Pregnancy-related low back pain

Pregnancy related low back pain is a common complaint among pregnant women. It can potentially have a negative impact on their quality of life. The aim of this article is to present a current review of the literature concerning this issue.By using PubMed database and low back pain, pelvic girdle pain, pregnancy as keywords, abstracts and original articles in English investigating the diagnosis treatment of back pain during pregnancy were searched and analyzedLow back pain could present as either a pelvic girdle pain between the posterior iliac crest and the gluteal fold or as a lumbar pain over and around the lumbar spine. The source of the pain should be diagnosed and differentiated early.The appropriate treatment aims to reduce the discomfort and the impact on the pregnant womans quality of life. This article reveals the most common risk factors, as well as treatment methods, which may help to alleviate the pain. Some suggestions for additional research are also discussed.

The impact of bone mineral density on the degree of curvature of the lumbar spine

OBJECTIVE

The prevailing perception is that one of the causes of postural deformities is osteoporosis. Nonetheless, studies of the correlation between bone mineral density (BMD) and spinal curvatures have produced contradictory results. This study was undertaken in order to determine whether (BMD) is associated with the curvature of the lumbar spine.

METHODS

105 postmenopausal women, aged 45-76 years (average= 57.3 years), were examined. All the participants underwent DXA scanning and spinal radiography using the same equipment and techniques. Lumbar curvatures were measured using the Cobb method. Subjects were divided according to their T-score into osteoporosis patients (n=54) and controls (n=51). Statistical analysis was performed using one way ANOVA, Mann-Whitney as well as Pearson and Spearman rank correlations.

RESULTS

There were no statistically significant correlations between BMD and lumbar curvature angles either in the total sample or in either group individually. Furthermore, these angles were not significantly different between patients with osteoporosis and controls.

CONCLUSIONS

The reduction in BMD and the alteration of the lumbar curvature that are observed in elderly individuals are concurrent but not related phenomena. The findings of this study contradict the claim that reduced bone mineral density is the cause of postural deformities.

Heparin regulates colon cancer cell growth through p38 mitogen-activated protein kinase signalling

OBJECTIVES

Heparin acts as an extracellular stimulus capable of activating major cell signalling pathways. Thus, we examined the putative mechanisms utilized by heparin to stimulate HT29, SW1116 and HCT116 colon cancer cell growth.

MATERIALS AND METHODS

Possible participation of the mitogen-activated protein kinase (MAPK) cascade on heparin-induced HT29, SW1116 and HCT116 colon cancer cell growth was evaluated using specific MAPK cascade inhibitors, Western blot analysis, real-time quantitative PCR and FACS apoptosis analysis.

RESULTS

Treatment with a highly specific p38 kinase inhibitor, SB203580, significantly (50-70%) inhibited heparin-induced colon cancer cell growth, demonstrating that p38 MAPK signalling is involved in their heparin-induced proliferative response. This was shown to be correlated with increased (up to 3-fold) phosphorylation of 181/182 threonine/tyrosine residues on p38 MAP kinase. Furthermore, heparin inhibited cyclin-dependent kinase inhibitor p21(WAF1/CIP1) and p53 tumour suppressor gene and protein expression up to 2-fold or 1.8-fold, respectively, and stimulated cyclin D1 expression up to 1.8-fold, in these cell lines through a p38-mediated mechanism. On the other hand, treatment with heparin did not appear to affect HT29, SW1116 and HCT116 cell levels of apoptosis.

CONCLUSIONS

This study demonstrates that an extracellular glycosaminoglycan, heparin, finely modulates expression of genes crucial to cell cycle regulation through specific activation of p38 MAP kinase to stimulate colon cancer cell growth.

Lumican, a small leucine-rich proteoglycan

Lumican belongs to the family of small leucine-rich repeat proteoglycans. Recent studies have shown that lumican participates in the maintenance of tissue homeostasis and modulates cellular functions including cell proliferation, migration, and differentiation. The expression of lumican has been correlated to the growth and metastasis of various malignancies; however, its exact role in tumorogenesis remains elusive. This review focuses upon the role of lumican in cell biology, providing insights into molecular mechanisms that lumican likely utilizes to control processes relevant to tumorogenesis.

Mechanoreceptors of the Posterior Cruciate Ligament

The mechanical role of the anterior and posterior cruciate ligaments in the passive and functional stability of the knee joint has been well documented. Both these knee joint ligaments contain Ruffini, Pacinian, Golgi and free nerve endings with different capabilities of providing the central nervous system with information regarding movement and position as well as chemical events. The posterior cruciate ligament provides 95% of the restraining force to a posterior tibial displacement, is significantly stronger than the other knee ligaments, and sensory nerve endings are located in the tibia and femoral bone insertions. This report aims to review the anatomy and physiology of the various mechanoreceptors of the posterior cruciate ligament, placing special emphasis on their role in knee joint stability. It concludes that the posterior crude ligament may not only serve as a ‘mechanical stabilizer’ of the knee joint, but also probably has an important ‘sensory function’ that should be taken into account when dealing with injuries to it.

Regulation of hyaluronan and versican deposition by growth factors in fibrosarcoma cell lines

Versican, a large chondroitin sulphate proteoglycan and hyaluronan (HA), a non-sulphated glycosaminoglycan are major constituents of the pericellular matrix. In many neoplastic tissues, changes in the expression of versican and HA affect tumour progression. Here, we analyse the synthesis of versican and hyaluronan by fibrosarcoma cells, and document how the latter is affected by PDGF-BB, bFGF and TGFB2, growth factors endogenously produced by these cells. Fibrosarcoma cell lines B6FS and HT1080 were utilised and compared with normal lung fibroblasts (DLF). The major versican isoforms expressed by DLF and B6FS cells were V0 and V1. Treatment of B6FS cells with TGFB2 showed a significant increase of V0 and V1 mRNAs. Versican expression in HT1080 cells was not significantly affected by any of the growth factors. In addition, TGFB2 treatment increased versican protein in DLF cells. HA, showed approximately a 2-fold and a 9-fold higher production in DLF cells compared to B6FS and HT1080 cells, respectively. In HT1080 cells, HA biosynthesis was significantly increased by bFGF, whereas, in B6FS cells it was increased by TGFB2 and PDGF-BB. Furthermore, analysis of HA synthases (HAS) expression indicated that HT1080 expressed similar levels of all three HAS isoforms in the following order: HAS2> HAS3> HAS1. bFGF shifted that balance by increasing the abundance of HAS1. The major HAS isoform expressed by B6FS cells was HAS2. PDGF-BB and TGFB2 showed the most prominent effects by increasing both HAS2 and HAS1 isoforms. In conclusion, these growth factors modulated, through upregulation of specific HAS isoforms, HA synthesis, secretion and net deposition to the pericellular matrix.

Balloon kyphoplasty as a single or as an adjunct procedure for the management of symptomatic vertebral haemangiomas

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective.

Chondroitin sulfate and heparan sulfate-containing proteoglycans are both partners and targets of basic fibroblast growth factor-mediated proliferation in human metastatic melanoma cell lines

Basic fibroblast growth factor (FGF-2) and its respective tyrosine kinase receptors, form an autocrine loop that affects human melanoma growth and metastasis. The aim of the present study was to examine the possible participation of various glycosaminoglycans, i.e. chondroitin sulfate, dermatan sulfate and heparin on basal and FGF-2-induced growth of WM9 and M5 human metastatic melanoma cells. Exogenous glycosaminoglycans mildly inhibited WM9 cell's proliferation, which was abolished by FGF-2. Treatment with the specific inhibitor of the glycosaminoglycan sulfation, sodium chlorate, demonstrated that endogenous glycosaminoglycan/proteoglycan production is required for both basal and stimulated by FGF-2 proliferation of these cells. Heparin capably restored their growth, and unexpectedly exogenous chondroitin sulfate to WM9 and both chondroitin sulfate and dermatan sulfate to M5 cells allowed FGF-2 mitogenic stimulation. Furthermore, in WM9 cells the degradation of membrane-bound chondroitin/dermatan sulfate stimulates basal growth and even enhances FGF-2 stimulation. The specific tyrosine kinase inhibitor, genistein completely blocked the effects of FGF-2 and glycosaminoglycans on melanoma proliferation whereas the use of the neutralizing antibody for FGF-2 showed that the mitogenic effect of chondroitin sulfate involves the interaction of FGF-2 with its receptors. Both the amounts of chondroitin/dermatan/heparan sulfate and their sulfation levels differed between the cell lines and were distinctly modulated by FGF-2. In this study, we show that chondroitin/dermatan sulfate-containing proteoglycans, likely in cooperation with heparan sulfate, participate in metastatic melanoma cell FGF-2-induced mitogenic response, which represents a novel finding and establishes the central role of sulfated glycosaminoglycans on melanoma growth.

Expression and distribution ofN-acetyl andN-glycolylneuraminic acids in secreted and cell-associated glycoconjugates by two human osteosarcoma cell lines

N-acetylneuraminic acid (Neu5Ac) and N-glycolylneuraminic acid (Neu5Gc) are the dominant sialic acids (Sia) in mammals usually found in the non-reducing terminal of oligosaccharide side chains in glycoproteins and glycolipids. Their expression and distribution pattern have been correlated both with the malignant phenotype and tumor grade of human cancers. The aim of the present study was to determine by reversed-phase HPLC method the amounts of Neu5Ac and Neu5Gc as well as their distribution among the culture media and cell surface of MG-63 and Saos-2 human osteosarcoma cell lines of high and low metastatic potential. It was determined that MG-63 cells produce up to 5-fold more total sialic acid as compared with the Saos 2 cells. Neu5Ac accounts for ca 60% of the total sialic acids secreted by MG-63 cells, whereas Neu5Gc is the predominant sialic acid present on the MG-63 cell membrane. Saos 2 cells secrete considerable amounts of Neu5Ac to culture media. The obtained data indicate that the human osteosarcoma cells express both forms of Sia-containing glycoconjugates; the differences in the amounts of each of the two major Sia types and their distribution may be related to their differences in morphology and/or metastatic potentials.

Transforming growth factor-beta as a key molecule triggering the expression of versican isoforms v0 and v1, hyaluronan synthase-2 and synthesis of hyaluronan in malignant osteosarcoma cells

Versican, a large sized chondroitin-sulphate proteoglycan (PG), and its binding partner, hyaluronan (HA), are extracellular matrix (ECM) components that play an essential role in transformed cell behavior. Expression of certain versican isoforms has been implicated in cell migration and proliferation of cancer cells and, on the other hand, disruption of HA synthesis by inhibiting hyaluronan synthase-2 (HAS2) expression in osteosarcoma cells by suppressing cell proliferation, invasiveness and motility. Considering that growth factors, such as TGF-beta, bFGF and PDGF-BB, are important regulators for the expression of the ECM macromolecules, in this study we examined the effect of these growth factors on the expression of the various versican isoforms, HA synthases as well as HA synthesis by MG-63 osteosarcoma cells and normal human osteoblastic periodontal ligament cells (hPDL). Real-time PCR and metabolic labelling followed by fine HPLC analysis coupled to radiochemical detection were the methods utilized. It was found that, contrary to normal hPDL cells, osteosarcoma MG-63 cells do not constitutively express the versican isoforms V0 and V1. Exogenous addition of TGF-beta2 stimulated the versican transcript levels mainly by forcing osteosarcoma cells to express V1 and V0 isoforms. PDGF-BB and bFGF had only minor effects in these cells. In hPDL cells a strong stimulation of the V3 transcript by all growth factors was observed. TGF-beta2 was also the major stimulator of HAS2 isoform expression as well as hyaluronan synthesis in osteosarcoma cells, while PDGF-BB exerted dominant influence on HAS2 isoform expression and hyaluronan biosynthesis by osteoblasts. The obtained results show for the first time that TGF-beta2 triggers the malignant phenotype pattern of versican and hyaluronan expression in human osteosarcoma cells and indicate that this growth factor may account for the metastatic potential of these cells.

The effectiveness of calcitonin on chronic back pain and daily activities in postmenopausal women with osteoporosis

The aim of this study was to investigate the effect of nasal calcitonin on chronic back pain and disability attributed to osteoporosis. The study design involved three groups of osteoporotic postmenopausal women suffering from chronic back pain. Group I consisted of 40 women with vertebral fractures, group II of 30 women with degenerative disorders and group III of 40 patients with non specific chronic back pain and without abnormality on plain X-rays. Pain intensity was measured using a numerical rating scale (NRS) and disability due to back pain was measured using the Oswestry disability questionnaire. The patients were randomly assigned to receive, for three months, either 200 IU intranasal salmon calcitonin and 1,000 mg of oral calcium daily (groups IA, IIA, IIIA) or 1,000 mg of oral calcium daily (groups IB, IIB, IIIB). Repeated measures ANOVA showed that there were no significant time, group or interaction effects for pain intensity and disability in any of the groups studied. Mean Oswestry and NRS scores were reduced during the follow-up period in the groups IA, IIIA, but the differences between the two time points were not statistically significant. Intranasal calcitonin has no effect on chronic back pain intensity and functional capacity of osteoporotic women regardless of the presence of fractures, degenerative disorders or chronic back pain of non-specific etiology.

Increased cell apoptosis in bone marrow trephine biopsies and immunomagnetically isolated myeloid progenitor cells in patients with chronic idiopathic neutropenia

The frequency of apoptotic cells in bone marrow trephine biopsies and cytospins of immunomagnetically isolated myeloid progenitor cells was determined in 39 patients with chronic idiopathic neutropenia (CIN) and 12 hematologically normal individuals using the in situ end-labeling (ISEL) apoptosis detection method. We found that 66.7% of the patients but none of the normal controls displayed apoptotic cells equal to or higher than 5% of the total mononuclear cells in bone marrow biopsies (p<0.01). In the double stain, we also found that the proportion of apoptotic CD15(+) myeloid precursor cells did not differ significantly between patients and control subjects, while the proportion of apoptotic CD34(+) hemopoietic cells could not be estimated with accuracy because of the presence of CD34(+) endothelial cells. Significantly increased apoptosis was noted in cytospins of immunomagnetically isolated patient CD34(+) and CD34(+)/CD33(+) cells but not CD34(-)/CD33(+) cells, compared to the controls ( p<0.001, p<0.02 and p>0.05, respectively). These findings confirm and extend our previous observations in flow-cytometric studies of apoptosis in CIN, indicating that increased apoptosis in CIN bone marrow concerns mainly the CD34(+) and CD34(+)/CD33(+) progenitor cell compartments. We conclude that the accelerated apoptosis in these compartments may account for the impaired neutrophil production in CIN patients.

Functional outcome of burst fractures of the thoracolumbar spine managed non-operatively, with early ambulation, evaluated using the load sharing classification

The purpose of this prospective study was to assess the functional outcome of conservative treatment with early ambulation of thoracolumbar burst fractures, using the Load Sharing classification. From 1997 to 2001, 60 consecutive patients with single-level thoracolumbar spinal injury, with no neurological impairment, were classified according to the Load Sharing scoring and were managed non-operatively. A custom-made thoracolumbosacral orthosis was worn by all patients for six months, and early ambulation was recommended. Several radiological parameters were evaluated; the Denis Pain and Work Scale was used to assess the clinical outcome. The average follow-up period was 42 months (range, 24 to 55 months). During this period the spinal canal occupation was significantly reduced. Other radiological parameters, such as Cobb's angle and anterior vertebral body compression, showed loss of fracture reduction, which was not statistically significant. However, the functional outcome was satisfactory in 55 of 60 patients with no complications recorded on completion of treatment. Load Sharing scoring is a reliable and easy-to-use classification for the conservative treatment and prognosis of thoracolumbar spinal fractures. Because of the three characteristics of the fracture site this classification can also predict the structural results of spinal injury, such as posttraumatic kyphosis, as well as the functional outcome in conservatively treated patients.

Posterior compact Cotrel-Dubousset instrumentation for occipitocervical, cervical and cervicothoracic fusion

The authors report on 32 consecutive patients with instability at the craniocervical, cervical and cervicothoracic regions suffering from various pathologies, who were treated with posterior instrumentation and fusion using the posterior hooks-rods-plate cervical compact Cotrel-Dubousset (CCD) instrumentation alone or, in three patients, in combination with anterior operation. The patients were observed postoperatively for an average of 31 months (range 25-44 months) and evaluated both clinically and radiographically using the following parameters: spine anatomy and reconstruction, sagittal profile, neurologic status, functional level, complications and status of arthrodesis. All patients but one (who died) achieved a solid arthrodesis based on plain and flexion/extension roentgenograms. Cervical lordosis (skull-C7) and cervicothoracic kyphosis (C7-T2) was improved by instrumentation towards a physiological lateral curve by an average of 33% (P<0.05) and 28% (P<0.05) respectively. Anterior vertebral olisthesis was reduced in the craniocervical and cervicothoracic region, by 73% and 90% respectively. At final follow-up there was an improvement of the neurologic Frankel status by an average of 1.2 grades and of myelopathy in 75% of the operated patients. Good to excellent functional results were seen in 77% of the operated patients, while acute and chronic pain was reduced by an average of 2.4 grades, on a scale of 0-3, in operated patients. No neurovascular or pulmonary complications arose from surgery. There was no significant change in lateral spine profile and olisthesis at the latest follow-up evaluation. There were no instrument-related failures. One patient requested hardware removal in the hope of reducing postoperative pain in the cervicothoracic region. The poor and fair results were related to the lack of improvement of neurologic impairment and myelopathy. The results of this study demonstrate that cervical CCD instrumentation applied in the region of the skull to the upper thoracic region for various disorders is a simple and safe instrumentation that restores lateral spine alignment, improves the potential for a solid fusion and offers sufficient functional results in the vast majority of the operated patients. However, the use of hooks in spinal stenosis is contraindicated.

An individualized approach for the implantation of a humeral prosthesis with the proper retroversion in fractures

We applied a new methodology in 7 patients with a fracture of the upper humeral head that required hemiarthroplasty, to implant a humeral prosthesis with an individualized posterior version. Our goal was to determine preoperatively the distance from the posterior edge of the bicipital groove where the lateral fin of the humeral prosthesis should sit, in order to reproduce the individual retroversion during surgery. Using three computed tomography scan sections of the upper humerus and image processing software, we estimated the above-mentioned distance in the sound humerus and implanted the prosthesis in each patient accordingly. The differences in retroversion between the left and right humeral heads permit a better approximation to normal applying this methodology than inserting the prosthesis in a standard retroversion.

The bicipital groove as a landmark for orientation of the humeral prosthesis in cases of fracture

We studied 45 dry cadaveric humeri to determine whether the bicipital groove of the humerus can be used as a landmark for a proper, individualized orientation of a humeral prosthesis, especially in the case of a fracture. We performed 3 computed tomography sections (at a level just below the lower portion of the head, at the middle of the humeral head, and at a distance 5 cm below the first section), and we used special software for 3-dimensional image processing. To reproduce the individual posterior version of the head, when a humeral prosthesis is implanted for fracture, the lateral fin of the prosthesis should be a mean distance 5.2 +/- 2.6 mm (-1.5 to 10.7 mm) from the posterior edge of the bicipital groove. If the lateral fin of the humeral prosthesis seats just behind the posterior edge of the bicipital groove, a difference of -6.3 degrees to 41.7 degrees from the normal posterior version occurs. A new, simple methodology for an individualized posterior version of a humeral prosthesis in cases of fracture is proposed. We applied this in 6 consecutive patients with fracture of the humeral head that required hemiarthroplasty.

Medium- and long-term results of open reduction and internal fixation for unstable pelvic ring fractures

Over a 10-year period, 74 patients with unstable pelvic injuries were treated with open reduction and internal fixation. Radiographic and clinical follow-up averaged 71 months (range: 38-141 months). Satisfactory (ie, good and very good) radiographic results were obtained in 90% of patients. Clinical results were superior in patients without associated injuries (P=.05-.001). Most of the complications in this series were due to associated injuries. Sepsis was mostly due to open pelvic injuries and malunion to either lack of patient cooperation or inadequate open reduction and internal fixation. Careful preoperative analysis of the nature of the pelvic injury and selection of the appropriate operative technique for open reduction and internal fixation result in a satisfactory outcome for the majority of operative patients.

Epstein-Barr virus-associated high-grade anaplastic plasmacytoma in a renal transplant patient

Allograft transplant patients have an increased risk of developing polyclonal or monoclonal lymphoproliferative disorders, but high-grade anaplastic plasmacytomas are extremely rare in these patients. We present a renal transplant patient who developed multiple extramedullary high-grade anaplastic plasmacytomas in the oral cavity, the left maxillary antrum, the scalp, the thigh and the upper abdominal wall with no evidence of diffuse bone marrow infiltration. Epstein-Barr virus (EBV) mRNA transcripts were detected within the myeloma cells by in situ hybridization using EBER1-2 probes. Following discontinuation of immunosuppression applied, the patient was treated with a cyclophosphamide-prednisone regimen followed by local irradiation, and a complete remission was achieved within four weeks. We concluded that EBV-associated high-grade anaplastic plasmacytomas constitute one more type of post-transplant lymphoproliferative disorder, and that despite their characterization as highly malignant neoplasms, their clinical behavior is not always aggressive.

Operative treatment of unstable injuries of the cervicothoracic junction

The authors present their experience in the operative treatment of unstable lesions at the cervicothoracic junction. Ten patients, six men and four women, underwent operative procedures at the cervicothoracic junction (C7-T1) between 1990 and 1997. Six patients had sustained fracture-dislocations, three patients had metastases and one patient had a primary malignant lesion. All the patients had significant cervical pain and neurologic deficit. The spinal cord and nerves were decompressed in all cases. Posterior stabilization was accomplished using various types of implants including hooks, wires and rods. Anteriorly, the spine was stabilized with plates and screws. Partial or complete vertebrectomy was performed in five cases and a titanium cylinder or an iliac autograft replaced the vertebral body. Five patients were submitted to a posterior operation only, and the other five to bilateral procedures. In four of these a one-stage operation was performed and in the last case a two-stage procedure. The anatomic and biomechanical characteristics of the cervicothoracic junction require a precise pre-operative analysis of the local anatomy and the selection of the proper implants for anterior and posterior stabilization.

Mueller roof reinforcement rings. Medium-term results

Short term results of cemented acetabular reconstruction with the use of the Mueller reinforcement ring in 30 hips in 29 patients have been reported previously. The indications for reinforcement were primary and postrevision segmental, cavitary, and combined acetabular deficiencies. The current study reports the medium term clinical and radiologic results of 20 of the 29 patients who were surgically treated (18 primary and eight postrevision hips) and who underwent followup with detailed clinical and radiographic analysis within an average of 9 years (range, 7-12 years). In the latest followup, there has been a statistically insignificant decrease in clinical scores compared with those obtained immediately after surgery; the changes probably are a result of the patients' aging. The radiologic scores at the latest followup were lower, although not statistically significant, than those at the short term followup. The causes of the three ring failures that occurred 5, 8, and 8.5 years after surgery and required revision arthroplasty were either acute trauma or tuberculous arthritis. Three additional hips (two primary and one revision) had evidence of loosening in the ring and socket associated with symptomatology and were considered as hips with impending revision. The rate of success of primary implantation was 94% at 7 years, 86% at 10 years, and 86% at 12 years and was not statistically different from that of revision implantation, which was 86% in all three followup periods. In this small series this surgical technique was successful and effective and followed by good medium term clinical and radiographic results in primary and revision implantation in segmental, cavitary, or complex acetabular deficiencies and in osteoporotic or deficient acetabular bone.

Monoradiculopathy of the fifth lumbar nerve root due to lumbar disc herniation between lumbar one and lumbar two vertebrae

An extremely rare case is reported of a 34-year-old man who had a drop foot due to a herniated disc between the first and second lumbar vertebrae with a monoradiculopathy of the fifth lumbar nerve root. The diagnosis was made on the basis of myelography and magnetic resonance imaging (MRI), which revealed a disc centrolateral herniation at the level between the first and second lumbar vertebrae. The patient underwent anterior discectomy and fusion with the use of iliac bone graft. Because of increasing local kyphosis and associated symptoms, a posterior TSRH instrumentation was added successfully. Postoperatively the patient had alleviation of his symptoms, and at the 6-year follow-up evaluation, he was completely symptomless. The spine surgeon should be aware of the possibility of this rare location of lower lumbar nerve root compression within the dural sac. In such a case, myelography and MRI seemed to be superior to the computed tomography scan.

Limb arterial injuries associated with limb fractures: clinical presentation, assessment and management

OBJECTIVES

Review of limb arterial injuries associated with limb fractures.

DESIGN

Retrospective study.

SETTING

University Hospital.

MATERIALS AND METHODS

The clinical presentation, assessment and management of 25 patients with upper (seven) and lower (18) limb arterial injuries associated with limb bone fractures has been retrospectively reviewed.

MAIN RESULTS

Five patients presented with life threatening injuries and classic signs of acute limb ischaemia, 15 patients had an obvious limb arterial injury, and 5 presented with a suspected limb arterial injury. The site of arterial damage was: superficial femoral (4); popliteal (11); tibioperoneal trunk (3); anterior tibial (4); posterior tibial (3); peroneal (2); axillary (1); brachial (5); radial (4); and ulnar artery (4). The types of arterial repair were: autogenous vein interposition or bypass grafting (17); P.T.F.E. (2); end-to-end anastomosis (14); and ligation (8). The popliteal vein was injured in six cases, repaired in four and ligated in two; the superficial femoral vein was injured in four cases, repaired in three and ligated in one; and the axillary vein was injured in one case and was ligated. Primary nerve repair was employed in six out of seven injured nerves. Skeletal fixation preceded vascular repair in 21 patients and in four a Javid shunt was used. Intraoperative fasciotomy was performed in 12 out of 18 patients with lower limb ischaemia. Completion arteriography revealed residual thrombi in the distal foot of four patients, in whom intraarterial thrombolysis was effective. During the follow-up period of 1.5 to 2 years, the upper and lower limb preservation rate was 100 and 89%, respectively. The upper limb function was judged excellent in five patients, good in one and fair in one. In the lower limbs it was excellent in 11 patients, good in three, fair in one and poor in one.

CONCLUSIONS

To ensure life and functional limb salvage of patients with devastating vascular injuries, a well organised multidisciplinary approach is necessary.