Health-Related Quality of Life of Patients with Postural Kyphosis Compared to Spinal Deformities in Adolescence: A Cross-Sectional Study

AIM

To evaluate the quality of life of patients with postural kyphosis (PK) compared with those adolescent idiopathic scoliosis (AIS) and Scheuermann Kyphosis (SK).

MATERIAL AND METHODS

Health-related quality of life (HRQoL) of adolescents with PK who were admitted to our clinic between January 2020 and June 2022 was compared with that of patients with AIS and SK who were admitted during the same period by using the Scoliosis Research Society-22 (SRS-22) questionnaire. All patients were asked to complete the SRS-22 questionnaire before the radiological evaluation. In the radiological evaluation, the sagittal and coronal deformities of the patients were measured.

RESULTS

In total, 126 patients with PK were compared with age and sex-matched AIS patients and 42 SK patients. The mean SRS-22 function score of the PK group was 4.72 ± 0.3 while it was 4.38 ± 0.6 (p=0.015) in SK patients and it was 4.34 ± 0.6 (p < 0.001) in AIS patients. The mean SRS-22 pain scores of PK patients was 4.18 ± 0.7. The mean pain score was 3.68 ± 0.8 (p=0.033) in the SK group and 3.6 ± 0.8 (p=0.010) in the AIS group. Adolescents with PK perceived less pain than those with AIS or SK. The scores for the other domains of SRS-22 revealed no differences.

CONCLUSION

HRQoL of patients with PK is reduced, similar to that of patients with common structural spine deformities. Recognizing the effects of PK on the HRQoL in adolescents can help physicians to treat these patients.

Effect of clinical and radiological parameters on the quality of life in adult patients with untreated adolescent idiopathic scoliosis: a cross-sectional study

PURPOSE

The aim of this study is to evaluate the factors that affect health-related quality of life (HRQoL) in untreated adolescent idiopathic scoliosis (AIS) patients in adulthood. We investigate the effect of clinical and radiological parameters on the SRS-22 results.

METHODS

A total of 286 untreated adolescent idiopathic scoliosis patients at adult age between April 2021 and April 2022 who were admitted to our clinic were included in the study. Rotational deformities were evaluated with a scoliometer. Cobb angles, coronal balance, clavicle angle, coronal pelvic tilt, trunk shift, and apical vertebral translation were measured in standing anteroposterior X-rays. The effect of each clinical and radiological parameter on SRS-22 results was evaluated.

RESULTS

No correlation was found between gender, age, curve type, presence of gibbosity or diagnosis time, and SRS-22 scores. A negative correlation was found between the BMI of the patients and the self-image scores (r =  - 0.246, p < 0.01) and function scores (r =  - 0.193, p < 0.05). Main thoracic (MT) gibbosity negatively correlates with self-image and total SRS-22 scores. Also, negative correlations were found between lumbar/thoracolumbar (LTL) gibbosity, function, and pain scores. MT Cobb angle magnitude was negatively correlated with self-image, mental health, and total SRS-22 scores. There were negative correlations between clavicle angle and mental health score, coronal pelvic tilt and self-image score, and apical vertebral translation and pain score.

CONCLUSION

BMI, MT gibbosity, LTL gibbosity, MT Cobb angle, clavicle angle, coronal pelvic tilt, and apical vertebral translation were negatively correlated with SRS-22 domains in untreated AIS patients in adulthood.

Pelvic Incidence as a Prognostic Factor in Coccydynia

AIM

To evaluate the pelvic incidence (PI) of coccydynia patients treated by different methods and to determine whether it is a risk factor or a prognostic factor.

MATERIAL AND METHODS

Patients who were treated for coccydynia were evaluated retrospectively, and 110 patients were enrolled. Spinopelvic parameters were measured by using Surgimap software, and the position of the coccyx was evaluated according to the Postacchini classification. The results were compared to spinopelvic parameters of healthy population.

RESULTS

The mean PI of the coccydynia patients did not differ from the healthy population, and there were no differences between treatment subgroups. The Postacchini classification showed that patients with type-3 and type-4 configurations had higher PI. When treatment groups were evaluated according to Postacchini classification, 80% of the surgery group had type-3 and type-4 configurations (50%, 30% respectively).

CONCLUSION

This is the first study to evaluate the PI of coccydynia patients. Patients with higher PI were prone to having type-3 of type-4 coccyx configurations and undergoing surgical treatment.

Difference between Spinecor brace and Thoracolumbosacral orthosis for deformity correction and quality of life in adolescent idiopathic scoliosis

Although there are several conservative treatment options, only bracing has been found to be effective in preventing curve progression and a subsequent need for surgery in adolescent idiopathic scoliosis. The objective of this study is to compare the results of SpineCor brace and thoracolumbosacral orthosis (TLSO) for treatment of adolescent idiopathic scoliosis radiologically and clinically. Sixty-four patients with adolescent idiopathic scoliosis treated with brace included in this study. Height, T1-Coccygx distance, and gibbosity were measured. Rib hump deformity was evaluated with a scoliometer. An SRS-22 questionnaire was used to determine the quality of life of patients after the first year of brace treatment. Differences in Cobb angles and gibbosity were insignificant for both groups. SRS-22 questionnaire results showed significant differences in pain, self-image and function/activity subgroups. Patients' mental health and satisfaction scores were insignificant. These braces have a similar effect on deformity correction. The surgery rates and success rates of braces are approximately equal. The major difference between SpineCor and TLSO is health-related quality of life.

Pedobarographic measurements after repair of Achilles tendon by minimal invasive surgery

The aim of the current study was to assess the changes of plantar foot pressures with pedobarography in -patients with Achilles tendon repair by minimally -invasive surgical technique. This retrospective study consisted of 15 consecutive patients who were treated for acute Achilles' tendon repair with minimally invasive technique in our clinic in a two year period between 2010 and 2012. All patients were male. The mean age was 28.7 years (24-42) and the mean follow-up time was 2.3 years (1.5- 3). All patients had sports related Achilles' tendon rupture and all had undergone surgery in 24-48 hours. After surgery, extremity was immobilized with short leg cast for 6 weeks. Peak and mean heel and forefoot pressures in injured extremity were measured by -pedobarograph and compared with noninvolved foot. There wasn't any complication associated with -surgery such as wound problems, re rupture or -neurologic injury. Only three patients had some numbness at the incision site. When we compare the mean foot pressures between the operated foot and the normal foot, there was no statistical difference about peak and mean heel and forefoot plantar pressure between involved site and non involved site. As a result, Achilles tendon repair with minimal invasive technique and early rehabilitation may prevent changes of plantar foot pressure distribution.

Isolated Adult Tillaux Fracture Associated With Volkmann Fracture-A Unique Combination of Injuries: Report of Two Cases and Review of the Literature

Avulsion fractures of the anterior inferior tibiofibular ligament from its tibial attachment, Tillaux fractures, are usually seen in adolescents during the interval of the distal tibial epiphyseal closure. However, this pattern of fracture is rare in adult patients, because the ligaments will usually fail before the bone fails. Avulsion fracture of the posterior inferior tibiofibular ligament from its tibial attachment, Volkmann fracture, is the posterolateral counterpart of a similar injury. In the present study, the cases of 2 adult patients with simultaneous Tillaux and Volkmann fractures are reported and the mechanism of injury, diagnosis, and treatment discussed. This fracture pattern is extremely rare and, to the best of our knowledge, has not been previously reported.

Spiral-medial butterfly fractures (AO-12-B1) in distal diaphysis of humerus with rotational forces: preliminary results of open reduction and plate-screw fixation

OBJECTIVE

Humerus shaft fractures are frequent injuries in orthopedic practice and generally occurs with direct and indirect traumas. While the most of these fractures can be managed with conservative methods, in some situations surgery is needed. The aim of this study is to define a different mechanism and treatment result of  humerus spiral fractures with medial butterfly fragment (AO-12-B1).

PATIENTS AND METHODS

Between 2010 and 2013, 11 patients who had undergone surgery for spiral humerus shaft fracture with medial large butterfly fragment (AO type 12-B1) resulting from a motor vehicle accident were enrolled to the study. All data was retrieved from the hospital's database retrospectively. All fractures were closed type and all of the patients were treated with open reduction and plate osteosynthesis through lateral approach. Elbow and shoulder ROMs were examined for functional outcomes. The DASH (Disabilities of the Arm, Shoulder and Hand) scoring system was applied at the final follow-up visit.

RESULTS

There were 7 male and 4 female patients with a mean age of 36 years (range, 28-50 years). All of the fractures occurred with same mechanism resulting from motor vehicle accident. Conservative treatment was not considered for any of the cases. The mean time to surgery was 2 days (1-3 days). The mean postoperative follow-up period was 14 months (6-24 months). All fractures had healed completely at 3 months postoperatively. At the final follow-up visit the mean DASH score was 4.2 (3.3-6.7).

CONCLUSIONS

Humerus spiral shaft fractures with a large medial butterfly fragment can be seen in dashboard injuries. It is important to fix the medial large fragment anatomically and minimal invasively in order to achieve union and not to disturb the vascular supply.

Coronary artery bypass graft surgery in patients with left ventricular dysfunction

AIM

The aim of this study was to investigate effects of congestive heart failure on coronary revascularization results in patients with left ventricular dysfunction and operated for elective coronary revascularization.

METHODS

The data were collected retrospectively from 126 consecutive patients with left ventricular dysfunction caused by coronary artery disease between January 2007 and January 2012. Patients admitted to hospital with angina complaints without congestive heart failure symptoms were group 1 and patients with severe congestive heart failure symptoms were group 2. Accompanying diseases, postoperative complications and mortality were recorded.

RESULTS

There were 66 patients in group 1 and 60 patients in group 2. Postoperative maximal inotropic support was necessary in 24 (36.4%) patients in group 1 for a mean duration of 1.6±0.9 days and in 34 (56.7%) patients in group 2 for a mean duration of 2.9±0.7 days. The proportion of patients with postoperative stay at the intensive care unit longer than 48 hours was significantly higher in group 2 compared to group 1. (p=0.0001) Hospital mortality was significantly higher in group 2 compared to group 1. (p=0.0001) CONCLUSION: Congestive heart failure aggravates the outcome after coronary artery bypass surgery in patients with left ventricular dysfunction.

Late onset brachial artery thrombosis and total temporary peripheral neuropathy in a child with humerus supracondylar fracture: a case report

Pediatric supracondylar fractures of the humerus are generally associated with neurovascular complications due to the deformity and sharp nature of bone fragments. When treated inadequately, these injuries may result in catastrophic complications, such as Volkmann's contracture and amputation. To our knowledge, late onset brachial arterial thrombosis and total temporary peripheral neuropathy after surgery of pediatric supracondylar fracture in the setting of normal preoperative vascular examination has not been reported yet. In this study, a 2-year and 6- month-old girl, who had delayed brachial arterial thrombosis after a displaced humerus supracondylar fracture surgery treated with embolectomy, was reported. Total lesion of median, ulnar and radial nerves completely resolved four months after surgery. Close neurovascular monitoring on the postoperative phase especially in severely displaced supracondylar fractures is strongly emphasized even in the setting of well-perfused hand.

Reliability of the mangled extremity severity score in combat-related upper and lower extremity injuries

BACKGROUND

Decision of limb salvage or amputation is generally aided with several trauma scoring systems such as the mangled extremity severity score (MESS). However, the reliability of the injury scores in the settling of open fractures due to explosives and missiles is challenging. Mortality and morbidity of the extremity trauma due to firearms are generally associated with time delay in revascularization, injury mechanism, anatomy of the injured site, associated injuries, age and the environmental circumstance. The purpose of the retrospective study was to evaluate the extent of extremity injuries due to ballistic missiles and to detect the reliability of mangled extremity severity score (MESS) in both upper and lower extremities.

MATERIALS AND METHODS

Between 2004 and 2014, 139 Gustillo Anderson Type III open fractures of both the upper and lower extremities were enrolled in the study. Data for patient age, fire arm type, transporting time from the field to the hospital (and the method), injury severity scores, MESS scores, fracture types, amputation levels, bone fixation methods and postoperative infections and complications retrieved from the two level-2 trauma center's data base. Sensitivity, specificity, positive and negative predictive values of the MESS were calculated to detect the ability in deciding amputation in the mangled limb.

RESULTS

Amputation was performed in 39 extremities and limb salvage attempted in 100 extremities. The mean followup time was 14.6 months (range 6-32 months). In the amputated group, the mean MESS scores for upper and lower extremity were 8.8 (range 6-11) and 9.24 (range 6-11), respectively. In the limb salvage group, the mean MESS scores for upper and lower extremities were 5.29 (range 4-7) and 5.19 (range 3-8), respectively. Sensitivity of MESS in upper and lower extremities were calculated as 80% and 79.4% and positive predictive values detected as 55.55% and 83.3%, respectively. Specificity of MESS score for upper and lower extremities was 84% and 86.6%; negative predictive values were calculated as 95.45% and 90.2%, respectively.

CONCLUSION

MESS is not predictive in combat related extremity injuries especially if between a score of 6-8. Limb ischemia and presence or absence of shock can be used in initial decision-making for amputation.

Reconstruction of intercalary bone defects following bone tumor resection with segmental bone transport using an Ilizarov circular external fixator

AIM

The purpose of this retrospective study was to report the long-term follow-up results of the reconstruction of bony defects with Ilizarov distraction osteogenesis using the bone transport method following en bloc resection of bone tumors.

MATERIALS AND METHODS

En bloc resection was performed in 13 patients with bone tumors between October 1991 and December 2010 in our clinic. The mean age of the patients was 19.46 years (range 7-42 years) at the time of surgery. Histological diagnosis was osteosarcoma in seven cases, Ewing's sarcoma in three cases, giant cell tumor in one case, osteoblastoma in one case and fibrous dysplasia in one case. In all cases either the femur or tibia was involved.

RESULTS

The average follow-up period was 157.23 months (range 32-288 months), and the bone defect after resection was 14.61 cm ± (9-24 cm). The mean Musculoskeletal Tumor Society score of the patients was 89.46 (83-96) at the final follow-up. The mean Knee Society Scale scores of patients in whom reconstruction was performed around the knee joint were 74.3 (51-84). The mean foot and ankle disability index of patients with a tumor around the ankle joint was 81 (73-95). Quality of life of the patients according to the SF-36 and BQUILI indexes was scored as 104 (88-150) and 4 (0-13), respectively.

CONCLUSION

From the long-term follow-up results, reconstruction with distraction osteogenesis seems to be an efficient method in patients with long life expectancies. However, a long external fixation time is a disadvantage of this technique. Problems in patient compliance and possible complications such as nonunion should be managed promptly.

Is it necessary to use an intraluminal shunt in symptomatic patients with contralateral carotid artery stenosis?

BACKGROUND

We aimed to investigate our results of carotid endarterectomy operations in symptomatic patients operated by using an intraluminal shunt and without use of an intraluminal shunt in patients with contralateral carotid artery stenosis.

METHODS

We reviewed the results of 144 carotid endarterectomy operations in patients with contralateral carotid artery stenosis from January 2007 to December 2012. These patients were allocated in 2 groups. Group 1 (n = 70) consisted of the patients operated by using an intraluminal shunt and Group 2 (n = 74) consisted of the patients operated without use of an intraluminal shunt. Postoperative neurologic complications were recorded.

RESULTS

Temporary neurologic impairment developed in 3 (4.3%) patients postoperatively in group 1 and in 2 (2.7%) patients postoperatively in group 2. This difference was not statistically significant between groups (p = 0.675). None of the patients returned to operation theatre due to excessive bleeding postoperatively. The stroke/death rate was 0.7% in the study group.

CONCLUSIONS

We conclude that carotid endarterectomy in symptomatic patients with contralateral occlusion can be performed safely without the systematic use of a shunt. However, it is not possible to define exact indications for use of a shunt as we have no information on the reason why some surgeons used a shunt.

Surgical management of iatrogenic femoral artery pseudoaneurysms: A 10-year experience

BACKGROUND

Vascular complications of cardiac catheterization have increased in line with increasing number of percutaneous interventions. Open repair is the standard method of treatment for true and false aneurysms of femoral artery. We report results of patients operated due to femoral artery pseudoaneurysm after cardiac catheterization.

METHODS

Data from 12,261 patients who underwent percutaneous intervention for cardiac catheterization between January 2003 and January 2013 were evaluated. Diagnosis of pseudoaneurysm was established mainly by doppler ultrasonography in patients with complaints of pain and hematoma at the intervention site. Pseudoaneurysms less than 2 cm in diameter were treated non-operatively and were followed up by regular ultrasonographic examination at the outpatient clinic. Pseudoaneurysms with a diameter of 2 cm or more underwent primary repair. All patients were followed up for one year.

RESULTS

We detected 55 (0.44%) patients with femoral artery pseudoaneurysm and 42 of them were operated. The mean age was 60.7 ± 6.3 years. Thirty nine (94.5%) patients underwent elective surgery, three (5.5%) patients were operated on under emergency conditions. Operation was performed under local anesthesia in 32 patients, under local anesthesia and sedation in eight patients, and under general anesthesia in three patients. Location of the pseudoaneurysm was the superficial femoral artery in 29 (69%), the common femoral artery in nine (21.4%), and the deep femoral artery in four (9.6%) patients. No limb loss occurred, no patient died and no recurrence was detected during the follow up.

CONCLUSIONS

Performing vascular reconstruction before the rupture of pseudoaneurysm is important in terms of morbidity and mortality. We concluded that surgical repair in pseudoaneurysms larger than 20 mm is safe and essential.

Fluoroscopy for transpedicular screw placement in scoliosis: to what extent can radiation exposure be reduced by the freehand technique?

AIM

In spinal surgery, high doses of radiation are delivered during surgical procedures that require fluoroscopic control. The aim of this study was to determine the amount of radiation delivered from the fluoroscopic unit and also the factors to reduce the amount of radiation during the surgery of adolescent idiopathic scoliosis patients.

MATERIAL AND METHODS

In this retrospective study 21 patients with adolescent idiopathic scoliosis treated by transpedicular screws between 2009 and 2012 were enrolled the study. Dose Area Product (DAP) values , number of views obtained during screw placement and other data were retrieved from the medical records of the patients.

RESULTS

The mean number of transpedicular screws used was 18. An average of 10,1 vertebrae were instrumented. The mean number of images obtained was 7.76. Mean fluoroscopy time was 7.95 seconds. The total mean DAP was 64.6 cGy.cm < sup > 2 < /sup > .

CONCLUSION

The amount of ionizing radiation transmitted to the patient and the surgical team can be reduced by freehand insertion, confirmation of screw position by AP and lateral fluoroscopic views including more than one segment, the use of K-wires as a guide in spinal segments with abnormal pedicular anatomy and neuromonitorization of the patient during the surgical correction of adolescent idiopathic scoliosis.

Comparison of the efficacy of the cardiac hypothermia and normothermia to myocardial damage in coronary artery bypass graft surgery with systemic normothermic cardiopulmonary bypass

AIM

The aim of our research is to investigate the cardiac damage formed by either local cardiac hypothermia or cardiac normothermia technique in patients who undergone isolated coronary artery bypass graft (CABG) surgery.

METHODS

The total of 40 patients who underwent isolated CABG operation under normothermic cardiopulmonary bypass (CPB) were studied. Patients were randomly divided into two groups as cardiac hypothermia and cardiac normothermia. Myocardial temperature was measured from the interventricular septum before aortic cross-clamp (ACC) (baseline), the ACC 20th minutes (ischemia) and after 20 minutes removal of the ACC (reperfusion). The coronary sinus blood samples were simultaneously obtained from the retrograde cardioplegia cannula while myocardial temperature was being measured. Complement component 3 (C3), complement component 4 (C4), troponin I and tumor necrosis factor-alpha (TNF-α) was measured from the coronary sinus blood samples.

RESULTS

Myocardial temperature was between 18-28 °C (deep hypothermia) during ACC in group 1. Myocardial temperature was over 34 °C (normothermia) during ACC in group 2. TNF-α values of group 1 for ischemia and reperfusion were higher than group 2, and it was found statistically significant (P<0.05).

CONCLUSION

Myocardial damage was less than in normothermia group according to hypothermia group. The results show that ice-cold blood cardioplegia and local ice treatment of the heart during CPB seems to harm the heart more than warm blood cardioplegia.

Comparison between normothermic and mild hypothermic cardiopulmonary bypass in myocardial revascularization of patients with left ventricular dysfunction

AIMS

The aim of this study was to investigate whether normothermic bypass is superior to mild hypothermia in patients with poor left ventricular function. This was achieved by studying defibrillation rates, postoperative requirements of cardiac pacing or other morbidity issues and mortality in patients with left ventricular dysfunction operated upon for elective coronary revascularization.

METHODS

Data were collected retrospectively from 252 consecutive patients with left ventricular dysfunction (ejection fraction ≤35%) undergoing coronary revascularization between January 2005 and January 2011. Patients operated upon under mild hypothermia (32 ºC) were placed in Group 1 and under normothermia (≥35 ºC) were placed in Group 2. Comorbidities and postoperative complications were recorded.

RESULTS

There were 128 patients in Group 1 and 124 patients in Group 2. Plasma concentrations of CK-MB and troponin T peaked at 6 hours postoperatively, with no significant difference between the groups. Despite longer aortic cross-clamp time and total bypass time in Group 2, significantly less defibrillation requirement rates after aortic declamping was observed. Hospital mortality occured in 16 patients; 8 patients in each group.

CONCLUSIONS

Normothermia enables less requirement for defibrillation after aortic declamping and postoperative cardiac pacing in patients with left ventricular dysfunction, which may be interpreted as better myocardial protection under normothermic bypass. However, maintaining normothermia had no effect on postoperative stroke, postoperative atrial fibrillation, renal failure development and mortality.

Factors affecting the outcome of osteochondral autografting (mosaicplasty) in articular cartilage defects of the knee joint: retrospective analysis of 152 cases

OBJECTIVE

The purpose of this retrospective study was to evaluate the results and prognostic factors affecting the outcome of osteochondral autografting (mosaicplasty) in articular cartilage defects of the knee joint.

MATERIALS AND METHODS

One hundred fifty-two patients who underwent mosaicplasty for femoral condylar cartilage defects (modified Outerbridge classification: Grade III and IV) of the knee joint between 1998 and 2007 in our institution were included. There were 126 male and 26 female patients with a mean age of 24.8 ± 4.6 years. The average size of the lesion was 2.7 ± 0.7 cm(2). Of these patients, 33 had concomitant meniscal and/or cruciate ligament injuries which were treated simultaneously. All patients were followed up with a mean of 18.2 ± 4.2 months (range 12-24 months) using Lysholm knee score. We analyzed the relationship between the outcome variable (Lysholm knee score at the final follow-up) and the predictor variables (age, gender, lesion size, lesion grade, localization, accompanying intra-articular injuries and duration of follow-up).

RESULTS

The mean preoperative Lysholm knee score was 55.2 ± 3.6 points and increased to 88.2 ± 2.5 points at the final follow-up. There was a significant increase in Lysholm score during follow-up period (p = 0.0001). The results were excellent in 2 cases (1.3 %), good in 144 cases (94.7 %) and fair in 6 cases (3.9 %). No patients had infection, systemic complication and revision surgery. Backward regression analysis showed that age, lesion size, localization and associated intraarticular injuries are the only predictors of the final Lysholm knee score in best fit model (R (2) = 0.442, p = 0.0001). The linear regression equation was (Lysholm score at final follow-up) = 93.4 - [0.2 (age of patient) + 0.8 (lesion size) + 0.9 (localization) + 2.8 (presence of associated intraarticular injuries)].

CONCLUSIONS

Mosaicplasty is an effective technique for the treatment of articular cartilage defects of the knee joint which restores the joint function in a short period of follow-up. Furthermore, age, lesion size, localization, and concomitant surgical interventions are major factors affecting the final outcome. The final knee score deteriorates as the age of the patient and size of the lesion increases. Furthermore, concomitant surgical interventions and lesions located on the medial femoral condyle have a negative effect on the final knee score.

Osteochondrosis of the medial cuneiform bone in a child: a case report and review of 18 published cases

Although, osteochondrosis of tarsal and metatarsal bones are frequent in children, involvement of the cuneiform bone is rare. Because of its rarity, the relevant literature is composed of small case series and case reports. Here, we report the case of a 6-year-old boy with bilateral osteochondrosis of the medial cuneiform bone. Activity modification and analgesia were sufficient for the relief of symptoms during follow-up. We discuss the demographic and clinical characteristics, radiographic findings, and treatment of this rare entity with a review of literature.

LEVEL OF EVIDENCE

Therapeutic, Level IV, Case study.

The importance and efficacy of posterior only instrumentation and fusion for severe idiopathic scoliosis

AIM

In mild and moderate idiopathic scoliosis (IS), posterior only instrumentation and fusion can provide satisfactory reduction. However in severe and rigid curvatures, combined anterior and posterior fusion is generally required. In this study we have aimed to evaluate the efficacy of posterior only instrumentation in severe thoracolumbar scoliosis clinically and radiologically and compare these results with the literature.

MATERIAL AND METHODS

In this retrospective study, 29 consecutive patients with severe idiopathic scoliosis who underwent posterior only instrumentation and fusion between March 2003 and February 2011 were included the study. Radiological evaluation was performed with preoperative, postoperative and folllow up standing AP and lateral x-rays. Clinical evaluation was made with shoulder balance and trunk shift. REAULTS: Major curve magnitude decreased to 24,1° and compensatory curve magnitude decreased to 12.20° at postoperative period. There was no significant difference in sagittal plane angles. Major curve correction rate was %68,65 in screw only instrumentation and % 65 in hybrid instrumentation.

CONCLUSION

Transpedicular screw instrumentation in severe IS is a safe and effective method in proper hands when flexibility of the curve evaluated accurately in preoperative period.

Use of the iPhone for radiographic evaluation of hallux valgus

OBJECTIVE

The purpose of this study was to compare the measurements made using a smartphone accelerometer and computerized measurements as a reference in a series of 32 hallux valgus patients.

MATERIALS AND METHODS

Two observers used an iPhone to measure the hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (of anteroposterior foot radiographs in 32 patients with symptomatic hallux valgus on a computer screen. Digital angular measurements on the computer were set as the reference standard for analysis and comparison. The difference between computerized measurements and all iPhone measurements, and the difference between the first and second iPhone measurements for each observer were calculated. Inter- and intraobserver reliability of the smartphone measurement method was also tested.

RESULTS

The variability of all measurements was similar for the iPhone and the computer-assisted techniques. The concordance between iPhone and computer-assisted angular measurements was excellent for the HVA, IMA, and DMAA. The maximum mean difference between the two techniques was 1.25 ± 1.02° for HVA, 0.92 ± 0.92° for IMA, and 1.10 ± 0.82° for DMAA. The interobserver reliability was excellent for HVA, IMA, and DMAA. The maximum mean difference between observers was 1.31 ± 0.89° for HVA, 0.90 ± 0.92° for IMA, and 0.78 ± 0.87° for DMAA. The intraobserver reliability was excellent for HVA, IMA, and DMAA.

CONCLUSIONS

We conclude that the Hallux Angles software for the iPhone can be used for measurement of hallux valgus angles in clinical practice and even for research purposes. It is an accurate and reproducible method.

In vitro effects of lidocaine hydrochloride on coronary artery bypass grafts

AIM

Coronary artery bypass grafting (CABG) is one of the most common procedures performed to improve blood supply to myocardium. The characteristics of grafts, mechanical stress and pharmacological agents have substantial influence on the short and long term graft patency. Lidocaine is among the most frequently used antiarrhythmic agents perioperatively. The aim of this study was to evaluate the in vitro effects of lidocaine on internal mammarian artery (IMA), radial artery (RA) and saphenous vein (SV) grafts.

METHODS

Using standard tissue bath techniques, responses to increasing concentrations of lidocaine hydrochloride were obtained, in segments of IMA, RA and SV grafts. Twenty patients were enrolled in the study with a total number of 48 grafts (16 for IMA, RA and SV grafts each). In vitro lidocaine concentrations between 10(-9)M and 10(-3.5)M were studied to represent therapeutic plasma concentration of 1.5-5 mcg/mL.

RESULTS

In IMA and RA grafts, lidocaine hydrochloride caused vasodilatation (40.5±1.9% and 39.1±2.6 % respectively) at concentrations between 10(-9) to 10(-7.5) M while causing a dose dependent vasoconstriction response at concentrations above 10(-7.5) M. In SV graft samples, lidocain hydrochloride caused vasodilatation (24.4±1.9 %) at concentrations between 10(-9) to 10(-7) M while causing dose dependent vasoconstriction at concentrations above 10(-7) M. For vasoconstriction effect, mean±SD values for E(max) were calculated as: 120.1±6.6% in IMA, 83.35±5.06% in RA, and 154.0±13.8% in SV. The vasoconstriction in the SV samples was higher than in the RA and IMA. The mean ±SD LogEC(50) values were -5.15±0.27, -5.76±0.11 and -5.56±0.19 for SV, IMA and RA grafts respectively.) There was a statiscally significant differences in the Log EC(50) values between SV, IMA and RA (P<0.005)

CONCLUSION

Based on the results of our study, we conclude that, increasing doses of lidocaine in the perioperative period may cause vasospasm in IMA, RA and SV grafts. Thus, avoiding high doses may have a role in improving perioperative and long term mortality.

Bilateral congenital absence of flexor pollicis brevis and abductor pollicis brevis muscles with bilateral thenar atrophy: a case report

In this paper, we report a case of a 23-year-old male patient with bilateral absence of the flexor pollicis brevis and abductor pollicis brevis muscles with an intact functioning opponens pollicis and flexor pollicis longus muscles with bilateral thenar atrophy due to its rarity. All physical, neurological, ultrasonographic, direct radiographic, electromyographic and MRI studies were used to confirm and document this congenital anomaly.

Open mosaicplasty in osteochondral lesions of the talus: a prospective study

Osteochondral lesions of the talus present with symptoms of pain and painful motion, affecting the quality of the patient's daily life. We evaluated the 2-year short-term outcomes of patients whose large osteochondral lesions of the talus were treated with medial malleolar osteotomy and a mosaic graft harvested from the knee on the same side. A total of 32 patients who had cartilage lesions due to osteochondritis dissecans in the medial aspect of the talus underwent mosaicplasty after medial malleolar osteotomy. The patients were followed up for a mean period of 16.8 (range 12 to 24) months. The staging and treatment plan of the osteochondral lesions of the talus were made according to the Bristol classification. The follow-up protocol for the patients included direct radiography and magnetic resonance imaging. The American Orthopaedic Foot and Ankle Society scoring system was used to assess the patients during the pre- and postoperative periods. Of the 32 patients, 3 (9.4%) were female and 29 (90.6%) male, with a mean age of 27.5 (range 20 to 47) years. The mean preoperative American Orthopaedic Foot and Ankle Society score was 59.12 ± 7.72 but had increased to 87.94 ± 3.55 during the postoperative 2 years. The increase in American Orthopaedic Foot and Ankle Society score was statistically significant (p < .05). We have concluded that open mosaicplasty is a reliable and effective method for the treatment of osteochondral lesions with subchondral cyst formation in the talus, exceeding 1.5 cm in diameter.

Evaluation of iloprost to prevent vasospasm in coronary artery bypass grafts

This study assessed the efficacy of iloprost in relieving vasospasm in coronary artery bypass grafts. Radial artery (RA), left internal thoracic artery (LITA) and saphenous vein (SV) grafts were taken from 20 patients (13 men and seven women, mean age 63.8 years [range 48-74 years]) scheduled to undergo coronary artery bypass grafting. Ten 3 mm vascular rings were cut from each graft and kept under tension for at least 60 min. They were kept alive with 37 degrees C oxygenated Krebs solution. Smooth muscle contraction was achieved with phenylephrine before iloprost was administered every 2 min, starting at a concentration of 10(-9) mol/l and increasing in logarithmic increments to a concentration of 10(-5) mol/l. The vasodilation response to iloprost started in all samples at a concentration of 10(-9) mol/l and increased with each incremental increase in iloprost concentration up to 10(-5) mol/l. These data suggest that local administration of iloprost has a role in relieving graft vasospasm during harvesting and preparation for coronary artery bypass grafting.

The use of esmolol and magnesium to prevent haemodynamic responses to extubation after coronary artery grafting

BACKGROUND AND OBJECTIVE

The haemodynamic responses during extubation can cause complications after open-heart surgery. In this study, we aimed to examine the effect of esmolol and magnesium before extubation on these haemodynamic responses.

METHODS

Following the approval of local Ethics Committee, 120 patients having coronary artery bypass grafting with extubation in the intensive care unit were included in the study. Patients were allocated to receive esmolol 1 mg kg-1 (group I, n = 40), magnesium 30 mg kg-1 (Group II, n = 40) or normal saline (Group III, n = 40). Study medication was administered as a 20-min infusion in a volume of 20 mL. Patients were extubated just after termination of the infusion. Heart rate, blood pressure and central venous pressure were recorded prior to drug administration, before extubation, during extubation and 1 min after extubation.

RESULTS

Heart rate was lower in Group I than in Groups II (P < 0.05) and III (P < 0.001) and lower in Group II than in Group III (P < 0.05) during extubation. It was also lower in Group I than in Group III (P < 0.05) after extubation. Systolic blood pressure was lower in Group I than in Groups II and III (P < 0.001) during extubation. Diastolic blood pressure was higher in Group III than in Groups I and II during extubation (P < 0.001) and after extubation (P < 0.05). Mean arterial pressure was lower in Group I than in Groups II and III (P < 0.001) during extubation, lower in Group II than in Group III (P < 0.05) during extubation and lower in Group I than in Group III (P < 0.05) after extubation.

CONCLUSION

We found that using esmolol before extubation following coronary artery bypass graft surgery prevents undesirable haemodynamic responses while magnesium reduces undesirable haemodynamic responses but does not prevent them.

The role of N-acetylcysteine in lower extremity ischemia/reperfusions

AIM

To evaluate the efficacy of N-acetyl cysteine (NAC) in lower extremity ischemia/reperfusion.

METHODS

A total of 23 patients who underwent surgical intervention due to acute femoral artery occlusion were assigned into 2 groups: control group (group 1, n=12); and NAC group (group 2, n=11). Patients in NAC group received NAC before reperfusion, and 8 and 16 h after reperfusion (3x300 mg), while patients in control group received only NaCl 0.9% (3x100 mL). Catalase, malondialdehyde (MDA) and thiol concentrations were determined in femoral vein samples collected at 6 different time points: before reperfusion (t1), and 30 min (t2), 2 h (t3), 6 h (t4), 12 h (t5) and 24 h (t6) after reperfusion. Alveolar-arterial oxygen gradient (A-aO2) was calculated in radial artery blood samples simultaneously collected at the same time points.

RESULTS

No significant differences between the two groups with regard to age (control group 61+/-13 and NAC group 64+/-11 years), gender (control group M/F: 7/5, NAC 6/5) and the average time from onset of symptoms (control group 9.6+/-3.5 h, and NAC group 10.2+/-3.1 h) were present. Catalase enzyme activity increased with reperfusion in both groups and there were no differences between the two groups. MDA levels did not change significantly with reperfusion in NAC group, whereas they were significantly higher in control group at t2 and t3 compared to NAC group (P<0.05). Thiol concentrations decreased with reperfusion in control group, and in NAC group increases that started with reperfusion returned back to baseline levels after 24 hours. Although the A-aO2 gradient increased in both groups with the beginning of reperfusion, the most prominent increase occurred in control group (P<0.05).

CONCLUSIONS

In control group, the significant increase in MDA levels and A-aO2 gradient in reperfusion phase were considered a sign of local and end organ injury. We did not observe these changes in NAC performed group thus showing the efficacy of NAC.

Cytokine response in lower extremity ischaemia/reperfusion

We studied the local and systemic concentrations of pro-inflammatory cytokines produced during acute lower extremity ischaemia and following reperfusion in 19 patients undergoing thromboembolectomy of the femoral artery. Blood samples were taken from the femoral vein (local response) and radial artery (systemic response) in the ischaemic (baseline) phase, and 2, 12 and 24 h post-reperfusion. Associated lung injury was measured by the alveolar-arterial (A-a) oxygen gradient and post-reperfusion femoral vein plasma concentrations of creatinine kinase and lactic dehydrogenase were also measured. Local and systemic concentrations of interleukin (IL)-2 receptor and IL-6 (but not IL-1 beta) increased significantly after reperfusion. IL-8 concentration increased significantly in the radial artery. The high and progressively increasing concentration of IL-6 in the femoral vein suggests local production. The parallel increase in creatinine kinase concentration and A-a oxygen gradient indicates that IL-6 plays an important role in acute arterial occlusion and reperfusion injury.

The Importance of Aprotinin and Pentoxifylline in Preventing Leukocyte Sequestration and Lung Injury Caused by Protamine at the End of Cardiopulmonary Bypass Surgery

BACKGROUND

Protamine has adverse effects on pulmonary gas exchange during the postoperative period. The objective of this study was to investigate the importance of aprotinin and pentoxifylline in preventing the leukocyte sequestration and lung injury caused by protamine administered after the termination of cardiopulmonary bypass (CPB).

METHODS

Participants (n = 39) were allocated into three groups at the termination of CPB: Group 1, (control group, n = 16); Group 2 (aprotinin group, n = 12), who received protamine + aprotinin (15,000 IU/kg); and Group 3 (Pentoxifylline group, n = 11), who received protamine + pentoxifylline (10 mg/kg). Leukocyte counts in pulmonary and radial arteries were determined after the termination of CPB and before any drug was given (t1), and 5 minutes (t2), 2 hours (t3), 6 hours (t4) and 12 hours (t5) after the administration of protamine. Alveolar-arterial O2 gradient (A-aO2) and dynamic pulmonary compliance were measured at t1, t2 and t3.

RESULTS

In the control group, an increase in pulmonary leukocyte sequestration was observed 5 minutes and 2 hours after protamine administration, after which this difference disappeared. No significant degree of pulmonary sequestration was detected in any measurements after protamine was administered in the aprotinin and pentoxifylline (PTX) groups. Dynamic lung compliance was 50.1, 45.2 and 47.2 ml/cm H2O in the control group, 49.2, 61.1 and 56.3 ml/cm H2O in the aprotinin group, and 49.5, 54.5 and 50.4 ml/cm H2O in the PTX group. The A-aO2 gradient was 212.2, 263.3 and 254.3 mm Hg in the control group, 209.4, 257.1 and 217.3 mm Hg in the aprotinin group, and 211.3, 260.8 and 219.2 mm Hg in the PTX group.

CONCLUSION

Aprotinin and PTX treatments have favourable effects on lung function by reducing protamine-induced leukocyte sequestration into lungs at the end of CPB.

Bilateral retrosternal dislocation and hypertrophy of medial clavicular heads with compression to brachiocephalic vein

A 36-year-old woman with effort dyspnea for 2 years, venous congestion of the left arm for 6 months and who did not have a history of a thoracic trauma was hospitalized. Posterior bilateral dislocation of the sternoclavicular joints and compression of the brachiocephalic vein were diagnosed and conformed by computed tomography (CT). The joint could not be reduced because of the old dislocation and destruction of the joint in the operation. The heads of the clavicles were resected and the vein compression was eliminated. Six weeks later, venous congestion disappeared and the brachiocephalic vein was patent.

The effects of intracoronary administration of vitamin E on myocardial ischemia-reperfusion injury during coronary artery surgery

BACKGROUND

Vitamin E has a strong antioxidant capacity, and has been used in several ischemia-reperfusion studies. The aim of this study was to investigate the effects of water-soluble vitamin E (alpha-tocopherol) on myocardial protection during coronary artery surgery.

METHODS

Water soluble vitamin E (100 mg) in tepid saline (n = 14) or tepid saline alone (n = 16) was administered into the coronary arteries at the end of aortic cross-clamping. Cardiac troponin-I (cTn-I), MB-isoenzyme of creatine kinase (CK-MB), myoglobin, blood gas, and lactate levels in systemic and coronary sinus blood and hemodynamic variables were assessed during and after the operation.

RESULTS

Eight hours after reperfusion, cTn-I levels increased to 3.06 +/- 1.8 ng/ml and 6.97 +/- 3.9 ng/ml in the vitamin E group and control group, respectively (p = 0.01). Coronary sinus lactate concentration was 2.68 +/- 0.5 mmol/l in the vitamin E group and 4.01 +/- 1.5 mmol/l in the control group 60 minutes after reperfusion (p = 0.027).

CONCLUSIONS

Administration of vitamin E into the coronary arteries before removal of the aortic cross-clamp can reduce myocardial cell injury and protect the myocardium from ischemia-reperfusion injury.

The importance of pulmonary artery circulation during cardiopulmonary bypass

This study sought to determine changes in transpulmonary difference in blood cells and alveolar-arterial oxygen (A-aO2) gradient when pulmonary artery circulation was obstructed in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Eighteen patients were divided into group A (control group; X-clamp placed on aorta, n = 9) and group B (pulmonary ischaemia group; X-clamp placed on aorta and pulmonary artery, n = 9). Haematological parameters were compared before CPB and up to 90 min after declamping. A-aO2 gradient differences were compared before and 2 h and 6 h after declamping. A transpulmonary increase in leucocyte levels normalized after 60 min in group A but remained higher in group B. A transpulmonary increase in neutrophils normalized after 60 min in group A and 90 min in group B. Increased lymphocyte levels normalized after 30 min in group A and 90 min in group B. A-aO2 gradient was determined as: group A (294.8 +/- 74.3) and group B (321.2 +/- 73.3) before X-clamping; group A (132.7 +/- 22.7) and group B (236.6 +/- 41.5) 2 h after declamping; and group A (72.2 +/- 22.7) and group B (189.4 +/- 88.9) 6 h after declamping. When pulmonary artery circulation was obstructed during the X-clamping period, leucocyte, neutrophil and lymphocyte sequestration within both lungs increased, and an increased A-aO2 gradient was observed because of tissue damage. To prevent post-operative complications, precautions to maintain normal pulmonary artery circulation are recommended.

The effects of cardiopulmonary bypass on androgen hormones in coronary artery bypass surgery

The effects of testosterone on coronary vasomotor regulation have been described by several recent reports. Here we investigated changes in serum androgen levels during and after cardiopulmonary bypass (CPB) in patients who had undergone coronary artery bypass surgery. Serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate (DHEA sulphate) levels were evaluated in 38 male coronary artery bypass surgery patients using a chemical immunoassay technique. All hormone levels were corrected to account for haemodilution. Serum-free testosterone level decreased significantly during weaning from CPB (from 15.7 +/- 4.2 nmol/l to 6.2 +/- 2.8 nmol/l), and an even greater decrease was observed in the first post-operative day (5.4 +/- 3.1 nmol/l). On the seventh post-operative day, free testosterone levels reached a normal value (11.8 +/- 5.5 nmol/l), although they were still significantly lower compared with the pre-operative value. There were slight alterations in serum DHEA sulphate levels, although the only significant decrease occurred from the first to the seventh day post-operation (from 4.7 +/- 2.2 mumol/l to 3.7 +/- 1.8 mumol/l, respectively). Serum luteinizing hormone levels were decreased during weaning from CPB (from 4.8 +/- 2.1 mIU/ml to 3.9 +/- 1.8 mIU/ml), but increased rapidly to the pre-operative value (5.5 +/- 2.5 mIU/ml) at the first post-operative day. These results show that CPB affects serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate levels. The free testosterone level decreases significantly both during and after CPB surgery.

Efficacy of topically applied glutamate-aspartate and pentoxifylline solutions in decreasing myocardial damage during open-heart surgery in rats

During open-heart surgery, the period between cross-clamping and maintenance of homogeneous diastolic arrest is often accompanied by significant ischaemic-hypoxic injury. The topical application of glutamate-aspartate or pentoxifylline may reduce energy demands during this period and thus prevent myocardial damage. Fifty rats were divided into five groups. In group A (control) the pericardial cavity was opened, all inlet and outlet vasculature cross-clamped, and the heart excised after 60 s. In groups B-E, the pericardial cavity was opened, all inlet and outlet vasculature cross-clamped for 60 s (groups B and D) or 90 s (groups C and E), and the pericardial cavity filled with glutamate-aspartate solution (groups B and C) or pentoxifylline solution (groups D and E) for 2 min. Following clamping, blood was withdrawn from the right atrium for biochemical analysis, and the heart excised for histological analysis. Histopathological and biochemical analysis showed a significant reduction in ischaemic-hypoxic cardiac injury in rats treated with topically applied glutamate-aspartate or pentoxifylline.

CT and MR imaging of the liver using liver-specific contrast media. A comparative study in a tumour model

PURPOSE

A new type of liposomal liver-specific contrast medium (CM) in CT was studied, and the results were compared with those obtained with Mn-DPDP, a paramagnetic hepatobiliary CM, in MR imaging. The contrasts of normal liver tissue to tumorous tissue and the importance of the CM for tumour detection in the 2 modalities were studied in a rabbit tumour model. CT and T1-weighted pre- and postcontrast and T2-weighted MR images precontrast were obtained.

MATERIAL, METHODS AND RESULTS

Compared to precontrast images, significantly higher contrasts of normal liver tissue to tumorous tissue were obtained after CM administration in both CT and MR examinations. At radiologic evaluation, significantly more tumours were detected after CM administration in CT and in T1-weighted MR images than in precontrast images in CT and T1-weighted MR. There were no significant differences in tumour detection frequency in MR studies including a T2-weighted pulse sequence, postcontrast CT, or postcontrast T1-weighted MR imaging.

CONCLUSION

The use of liver-specific CM improves visualization of liver tumours in CT and T1-weighted MR imaging.

Complement activation and histamine release following administration of roentgen contrast media

Anaphylactoid reactions following administration of reontgen contrast media (CM) have occasionally been described. In this investigation, blood samples for nonallergic human volunteers were exposed to the CM iodixanol (Visipaque), iohexol (Omnipaque), ioxaglate (Hexabrix) and metrizoate (Isopaque 350). The degree of activation of the complement cascade and the amount of free histamine in the samples were estimated. By using a hemolytic assay, a dose-independent complement consumption was detected when salt-free dilutions of the CM were added to human serum. Very little complement consumption was detectable when the concentrations, indicating that in the CM solutions were adjusted toward normal plasma concentrations, indicating that the lack of salts in the CM formulations was responsible for causing the consumption of complement rather than the CM molecules themselves. By using ELISA assay for determination of the terminal complement complex (TCC), no increase in TCC level was detected following the addition of iodixanol to human serum. The results indicate that iodixanol does not activate the complement cascade when added to human serum, and that it is unlikely that anaphylactoid reactions observed in man after CM administration are caused by CM-induced anaphylatoxins. No histamine release was observed following the addition of ioxaglate, metrizoate, iohexol or iodixanol to blood from nonallergic individuals.

Intravenous injection of Albunex microspheres causes thromboxane mediated pulmonary hypertension in pigs, but not in monkeys or rabbits

Intravenous injection of the ultrasound contrast agent Albunex (manufactured by Nycomed AS, Oslo, Norway; 400 million air-filled albumin microspheres per ml, mean diameter 4 +/- 1 microns) caused a dose-dependent increase of mean pulmonary arterial pressure in nine pigs. The highest dose (0.014 +/- 0.002 ml kg-1) increased mean pulmonary arterial pressure from 17 +/- 1 mmHg to 42 +/- 3 mmHg and decreased mean systemic arterial pressure from 111 +/- 9 to 93 +/- 12 mmHg. The pressure responses began 22 +/- 1 s after particle injection, and reached maximum after 51 +/- 3 s. No changes in mean pulmonary arterial pressure or mean systemic arterial pressure were observed after Albunex injections during treatment with indomethacin (10 mg kg-1 + 5 mg kg-1 h-1 i.v., n = 6) or the thromboxane A2 receptor antagonist HN-11500 (10 mg kg-1 + 5 mg kg-1 h-1 i.v., n = 3). No Doppler enhancement could be detected in a carotid artery following injection of 0.12 ml kg-1 Albunex during indomethacin treatment. In five rabbits, Albunex caused Doppler enhancement in a carotid artery, and 0.48 ml kg-1 did not affect mean pulmonary arterial pressure or other haemodynamic parameters in five rabbits or in three cynomolgus monkeys. The pressure response in pigs may be explained by release of thromboxane A2 from the pulmonary intravascular macrophages during phagocytosis of the microspheres. This response to Albunex was totally absent in rabbits and monkeys.

Enhancement of DNA-mediated gene transfer by inhibitors of autophagic-lysosomal function

A variety of compounds, known to influence the intravesicular transport and degradation of macromolecules, was studied for their effect on the efficiency of DNA-mediated gene transfer (transfection). The efficiency of transfection was measured by transformation of rat 2 thymidine kinase-deficient (tk-) cells by the cloned herpes simplex I thymidine kinase gene (pAGO). When salmon sperm DNA (average molecular weight, 6 X 10(6) D) was used as a carrier, the presence of either 20 mM NH4Cl, 1 microM carbonyl cyanide p-trifluoromethoxy phenyl hydrazone (FCCP), or 5 mM 3-methyl adenine (3-MA) in the medium during incubation of the cells with the DNA-calcium-phosphate (DNA-Ca-Pi) precipitate, enhanced the efficiency of transfection by a factor of 10. If rat thymus DNA (greater than 30 X 10(6) D) was used as a carrier, the transformation efficiency was much higher than with salmon sperm DNA. However, in this case treatment with 3-MA, NH4Cl and FCCP enhanced the transformation frequency by slightly less than a factor of two. 3-MA further increased the transfection frequency if the cells were incubated with the compound after removal of the DNA-Ca-Pi coprecipitate, whereas NH4Cl and FCCP had no such effect. Our results strongly suggest that these inhibitors of intracellular degradation can increase the frequency of transformation by increasing the cytoplasmic levels of exogenous DNA.