1
|
DeLong WG, Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW. Aggressive treatment of 119 open fracture wounds. THE JOURNAL OF TRAUMA 1999; 46:1049-54. [PMID: 10372623 DOI: 10.1097/00005373-199906000-00012] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to determine whether immediate primary closure of open fracture wounds can be performed without increasing the incidence of infections and delayed unions/nonunions. Although the traditional management of these injuries has been open treatment, a trend toward immediate primary closure has evolved on our service. METHODS All open fractures presenting to an urban Level I trauma center during a 42-month period were reviewed. Of the 127 patients with open fractures, 90 patients (119 open fractures) were initially treated at the above institution within 24 hours of injury, had fractures proximal to the carpus or tarsals, and were followed-up until fracture union. All patients underwent emergent wound irrigation and debridement. The method of fracture immobilization and timing of wound closure was left to the discretion of the attending orthopedic surgeon. Immediate primary closure was used in 22 of 25 Grade I open fractures (88%), 37 of 43 Grade II fractures (86%), 24 of 32 Grade IIIa fractures (75%), 4 of 12 Grade IIIb fractures (33%), and 0 of 7 Grade IIIc fractures (0%). RESULTS Eight fractures (7%) were complicated by a deep wound infection/osteomyelitis, and 19 fractures (16%) developed a delayed union/nonunion. Statistical analysis revealed no significant difference in delayed/nonunion and infection rates between immediate and delayed closures. CONCLUSION Immediate primary closure of open fracture wounds after a thorough debridement by an experienced fracture surgeon appears to cause no significant increase in infections or delayed union/nonunions. In addition, early closure may decrease the requirement for subsequent debridements and soft-tissue procedures, thereby minimizing surgical morbidity, shortening hospital stays, and reducing costs. We feel that a randomized, prospective study of this aggressive approach to open fracture care is warranted.
Collapse
|
Comparative Study |
26 |
96 |
2
|
Iannacone WM, Bennett FS, DeLong WG, Born CT, Dalsey RM. Initial experience with the treatment of supracondylar femoral fractures using the supracondylar intramedullary nail: a preliminary report. J Orthop Trauma 1994; 8:322-7. [PMID: 7965294 DOI: 10.1097/00005131-199408000-00008] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Initial experience at a Level I Trauma Center with the use of a retrograde supracondylar intramedullary (IM) nail for the treatment of supracondylar and supracondylar-intercondylar intraarticular fractures of the distal femur is presented. Thirty-eight patients with 41 complex distal femur fractures were treated with this newly developed retrograde IM rod. These included 22 open fractures and 19 closed fractures. Four nonunions occurred, but all progressed to union after revision internal fixation and bone grafting. Two of five delayed unions required revision fixation. Two required screw renewal and dynamization. Thirty-five of 41 knees achieved at least 90 degrees of knee motion. There were no infections and no problems with wound healing. Four patients developed fatigue fractures of the rod. These mechanical failures occurred when 11- and 12-mm nails were used in conjunction with 6.4-mm interlocking screws. The rod system was therefore modified to include 12- and 13-mm diameter nails and smaller 5.0-mm interlocking screws. There have been no subsequent nail failures. We are cautiously optimistic that supracondylar IM rod fixation will contribute to the management of these difficult fractures. However, further clinical trials and additional biomechanical testing should be undertaken prior to widespread use of this device.
Collapse
MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Biomechanical Phenomena
- Bone Nails/classification
- Bone Nails/standards
- Equipment Design
- Equipment Failure
- Female
- Femoral Fractures/diagnostic imaging
- Femoral Fractures/physiopathology
- Femoral Fractures/surgery
- Follow-Up Studies
- Fracture Fixation, Intramedullary/instrumentation
- Fracture Fixation, Intramedullary/methods
- Fracture Healing
- Fractures, Closed/diagnostic imaging
- Fractures, Closed/physiopathology
- Fractures, Closed/surgery
- Fractures, Open/diagnostic imaging
- Fractures, Open/physiopathology
- Fractures, Open/surgery
- Humans
- Male
- Middle Aged
- Multiple Trauma/diagnostic imaging
- Multiple Trauma/physiopathology
- Multiple Trauma/surgery
- Radiography
- Range of Motion, Articular
Collapse
|
Clinical Trial |
31 |
77 |
3
|
Born CT, Ross SE, Iannacone WM, Schwab CW, DeLong WG. Delayed identification of skeletal injury in multisystem trauma: the 'missed' fracture. THE JOURNAL OF TRAUMA 1989; 29:1643-6. [PMID: 2593194 DOI: 10.1097/00005373-198912000-00010] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Delay in diagnosis of musculoskeletal injury in multiply injured patients may potentially lead to functional or cosmetic disability in survivors. In an 18-month prospective study to determine the incidence and spectrum of delayed recognition of skeletal injury at our Level I trauma center, delayed diagnosis of 39 fractures was made in 26 of 1,006 consecutive blunt trauma patients. The delay in recognition ranged from 1-91 days. Twenty-one (55%) of the fractures were not X-rayed at the time of admission, but nine (23%) fractures were clearly visible on admission films. Four (10%) fractures were missed because of technically inadequate X-rays, and five (13%) had adequate X-rays but could not be identified on admission films. In only two instances was a second anesthetic exposure required for operative therapy. For the patients in this series, the delay of fracture identification was not felt to contribute to additional long-term cosmetic, functional, or neurologic problems. Continued clinical and radiologic surveillance is required in multiply injured patients to prevent musculoskeletal diagnostic failure.
Collapse
|
|
36 |
76 |
4
|
Kottmeier SA, Wilson SC, Born CT, Hanks GA, Iannacone WM, DeLong WG. Surgical management of soft tissue lesions associated with pelvic ring injury. Clin Orthop Relat Res 1996:46-53. [PMID: 8769435 DOI: 10.1097/00003086-199608000-00007] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Mortality rates associated with pelvic ring injury combined with open wounds have decreased considerably during the past 2 decades. Consequently, increased survivability has heightened the demand for definitive stabilization techniques to address pelvic ring instability. Control of hemorrhage and avoidance of sepsis remain paramount concerns in the initial and later stages of management, respectively. Exclusion of occult and readily apparent perforations of the genital urinary and gastrointestinal tracts is essential when using a multidisciplinary approach. Recognition of open and closed degloving injury patterns and appropriate adherence to treatment guidelines will optimize outcome and avoid catastrophic complication.
Collapse
|
Review |
29 |
72 |
5
|
Arnott JA, Zhang X, Sanjay A, Owen TA, Smock SL, Rehman S, DeLong WG, Safadi FF, Popoff SN. Molecular requirements for induction of CTGF expression by TGF-beta1 in primary osteoblasts. Bone 2008; 42:871-85. [PMID: 18314002 PMCID: PMC2430079 DOI: 10.1016/j.bone.2008.01.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Revised: 11/30/2007] [Accepted: 01/03/2008] [Indexed: 01/05/2023]
Abstract
Connective tissue growth factor (CTGF/CCN2) is a cysteine rich, extracellular matrix protein that acts as an anabolic growth factor to regulate osteoblast differentiation and function. In osteoblasts, CTGF is induced by TGF-beta1 where it acts as a downstream mediator of TGF-beta1 induced matrix production. The molecular mechanisms that control CTGF induction by TGF-beta1 in osteoblasts are not known. To assess the role of individual Smads in mediating the induction of CTGF by TGF-beta1, we used specific Smad siRNAs to block Smad expression. These studies demonstrated that Smads 3 and 4, but not Smad 2, are required for TGF-beta1 induced CTGF promoter activity and expression in osteoblasts. Since the activation of MAPKs (Erk, Jnk and p38) by TGF-beta1 is cell type specific, we were interested in determining the role of individual MAPKs in TGF-beta1 induction of CTGF promoter activity and expression. Using dominant negative (DN) mutants for Erk, Jnk and p38, we demonstrated that the expression of DN-Erk caused a significant inhibition of TGF-beta1 induced CTGF promoter activity. In contrast, the expression of DN-p38 or DN-Jnk failed to inhibit activation of CTGF promoter activity. To confirm the vital role of Erk, we used the Erk inhibitor (PD98059) to block its activation, demonstrating that it prevented TGF-beta1 activation of the CTGF promoter and up-regulation of CTGF expression in osteoblasts. Since Src can also act as a downstream signaling effector for TGF-beta in some cell types, we determined its role in TGF-beta1 induction of CTGF in osteoblasts. Treatment of osteoblasts with a Src family kinase inhibitor, PP2, or the expression of two independent kinase-dead Src mutant constructs caused significant inhibition of TGF-beta1 induced CTGF promoter activity and expression. Additionally, blocking Src activation prevented Erk activation by TGF-beta1 demonstrating a role for Src as an upstream mediator of Erk in regulating CTGF expression in osteoblasts. To investigate the involvement of the TGF-beta1 response element (TRE) and the SMAD binding element (SBE) in CTGF induction, we cloned the rat CTGF proximal promoter (-787 to +1) containing the TRE and SBE motifs into a pGL3-Luciferase reporter construct. Using a combination of CTGF promoter deletion constructs and site-directed mutants, we demonstrated the unique requirement of both the TRE and SBE for CTGF induction by TGF-beta1 in osteoblasts. Electro-mobility shift assays using specific probes containing the TRE, SBE or both showed TGF-beta1 inducible complexes that can be ablated by mutation of the respective motif, confirming their requirement for TGF-beta1 induced CTGF promoter activity. In conclusion, these studies demonstrate that CTGF induction by TGF-beta1 in osteoblasts involves Smads 3 and 4, the Erk and Src signaling pathways, and requires both the TRE and SBE motifs in the CTGF proximal promoter.
Collapse
|
Research Support, N.I.H., Extramural |
17 |
46 |
6
|
Ross SE, O'Malley KF, DeLong WG, Born CT, Schwab CW. Clinical predictors of unstable cervical spinal injury in multiply injured patients. Injury 1992; 23:317-9. [PMID: 1644462 DOI: 10.1016/0020-1383(92)90178-u] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
All victims of major blunt trauma have been said to be at risk of cervical spinal injury. In a prospective study of 410 such patients at our institution, we identified 13 patients (6.12 per cent) with unstable cervical spines. Loss or defect of consciousness following injury (regardless of duration), neurological deficit consistent with cervical cord or nerve root injury and neck tenderness were significantly predictive of an unstable cervical spine. Immediate radiographic investigation of the cervical spine is mandatory in such patients, but may not be required in patients without these signs.
Collapse
|
|
33 |
43 |
7
|
Wei SY, Born CT, Abene A, Ong A, Hayda R, DeLong WG. Diaphyseal forearm fractures treated with and without bone graft. THE JOURNAL OF TRAUMA 1999; 46:1045-8. [PMID: 10372622 DOI: 10.1097/00005373-199906000-00011] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to determine whether the acute bone grafting of diaphyseal forearm fractures decreases the incidence of nonunion and reduces the time to union. Although the traditional treatment of comminuted radius and/or ulnar shaft fractures involves bone graft, a recent report called into question this practice. PATIENTS A database search was used to identify all acute diaphyseal forearm fractures presenting to an urban Level I trauma center between 1988 and 1996. All radius and/or ulnar shaft fractures, as well as all Monteggia and Galeazzi fracture-dislocations, in patients with closed physes were included. The charts and operative reports were available for 64 diaphyseal forearm fractures in 49 patients. Fifty-six fractures were followed for at least 1 year beyond clinical and radiographic union. The injuries were treated with open reduction and plate fixation by experienced orthopedic traumatologists. All noncomminuted fractures were treated without bone graft. For the comminuted fractures, the decision to use bone graft was left to the discretion of the operating surgeon. RESULTS Overall, 55 of 56 fractures (98%) achieved union at a mean of 49 days (range, 19-123 days), with the only nonunion occurring in a patient with a closed, noncomminuted Galeazzi injury. Among the 20 noncomminuted fractures, all of which were treated without bone graft, 19 (95%) achieved union at a mean of 50 days (range, 19-102 days). Among the 36 comminuted fractures, all 25 treated without bone graft achieved fusion at an average of 50 days (range, 20-123 days) and all 11 treated with bone graft achieved union at an average of 45 days (range, 22-67 days). No statistically significant difference in the incidence of nonunion or time to union was noted between fractures that were treated with and without bone graft. CONCLUSION Acute bone grafting of diaphyseal forearm fractures did not affect the union rate or the time to union.
Collapse
|
Clinical Trial |
26 |
39 |
8
|
Iannacone WM, Taffet R, DeLong WG, Born CT, Dalsey RM, Deutsch LS. Early exchange intramedullary nailing of distal femoral fractures with vascular injury initially stabilized with external fixation. THE JOURNAL OF TRAUMA 1994; 37:446-51. [PMID: 8083908 DOI: 10.1097/00005373-199409000-00020] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Fracture of the femur with accompanying arterial injury represents approximately 1% of all femoral fractures. Controversy exists regarding the choice of fixation and the sequence of fixation and vascular repair. We report on the treatment of six patients with seven distal femoral fractures and angiographically documented arterial injuries treated over a 20-month period. The treatment protocol consisted of angiography followed by provisional external fixation and early primary exchange to an intramedullary nail. Five of the seven fractures were open. Three fractures were caused by blunt trauma, and four were secondary to shotgun blasts. Average follow-up was 12 months (range, 6-25 months). All fractures healed with an average time to union of 25 weeks. There were no complications related to the vascular repair. One case of an acute deep infection resolved after debridement and placement of polymethylmethacrylate cement beads impregnated with antibiotics and a course of intravenous antibiotics. All patients returned to their previous levels of activity. Based on the results of our experience with a small group of patients, we feel that this treatment protocol will prove to be a safe and efficient method of management of these difficult injuries.
Collapse
|
|
31 |
32 |
9
|
Bernstein J, Monaghan BA, Silber JS, DeLong WG. Taxonomy and treatment – a classification of fracture classifications. ACTA ACUST UNITED AC 1997. [DOI: 10.1302/0301-620x.79b5.0790706] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
|
28 |
27 |
10
|
DeLong WG, Born CT, Marcelli E, Shaikh KA, Iannacone WM, Schwab CW. Ender nail fixation in long bone fractures: experience in a level I trauma center. THE JOURNAL OF TRAUMA 1989; 29:571-6. [PMID: 2724374 DOI: 10.1097/00005373-198905000-00005] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Early fixation of extremity fractures in polytrauma patients is a well accepted and desirable treatment. In our patient population, the indications for immediate Ender nail fixation was for Grade I and Grade II open long bone fractures and closed long bone fractures in patients with small intramedullary canals. Ender nails were also used in patients in whom reaming was undesirable. This included patients with open physes for immediate fracture fixation and in those with Grade III open wounds in a delayed fashion. These flexible nails were also implemented for use to minimize anesthesia time as a life saving measure in the severely injured. This study is a retrospective review of a 30-month period in which 68 patients with 91 fractures underwent Ender intramedullary nailing. The mean Injury Severity Score (ISS) was 12.4. There were 16 humerus fractures, 26 femur fractures, and 49 tibia fractures. Thirty-three per cent (30 fractures) were open fractures. The average operating time per fracture was 70 minutes (range, 15 to 150 minutes). The estimated blood loss per fracture was 150 cc with a range of 25 to 500 cc. The average followup is currently 19 months (range was 8 to 29 months). This approach achieved an excellent result in 95% of the patients treated. There were no wound, soft-tissue, or bony infections experienced. Major complications were seen in five patients: three nonunions and two malunions.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
|
|
36 |
20 |
11
|
Born CT, Mure AJ, Iannacone WM, DeLong WG. Three-dimensional computerized tomographic demonstration of bilateral atlantoaxial rotatory dislocation in an adult: report of a case and review of the literature. J Orthop Trauma 1994; 8:67-72. [PMID: 8169700 DOI: 10.1097/00005131-199402000-00015] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A rare case of bilateral atlantoaxial rotatory dislocation (Fielding type V) in an adult is presented. The diagnosis was rapidly made by computed axial tomography. Prior reports of this entity have not clearly defined the pathoanatomy, which in our case was confirmed by three-dimensional tomographic reconstruction. We offer a clarification of the anatomic lesion and a discussion of this injury, which may make recognition and treatment of future cases easier.
Collapse
|
Case Reports |
31 |
20 |
12
|
Iannacone WM, DeLong WG, Born CT, Bednar JM, Ross SE. Dynamic computerized tomography of the occiput-atlas-axis complex in trauma patients with odontoid lateral mass asymmetry. THE JOURNAL OF TRAUMA 1990; 30:1501-5. [PMID: 2258961 DOI: 10.1097/00005373-199012000-00010] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Over a 23-month period, 25 patients aged 11 to 74 years presented to our Level I trauma center with odontoid lateral mass asymmetry of 2 to 5 mm on properly centered AP open-mouth X-rays: 32% of patients were asymptomatic, 68% had cervical pain, and 32% had limited range of motion. Patients with cervical spine fractures or dislocations and those with fixed deformity were excluded. The clinical significance of asymmetry was determined utilizing dynamic axial CT scanning of the occiput (C0), atlas (C1) and axis (C2) with the head neutral and with 15 degrees to 30 degrees active rotation. Nineteen patients demonstrated greater than 5 degrees of relative motion of C1 on C2 bilaterally. Three patients had less than 5 degrees of relative motion bilaterally and three patients had less than 5 degrees relative motion with left rotation only. No patient had formal treatment and all had nearly normal cervical range of motion on clinical examination at the time of hospital discharge. The finding of an asymmetric odontoid-lateral mass interspace on properly centered open-mouth AP X-rays in the presence of otherwise normal cervical spine X-rays, in conscious patients without fixed deformity, appears to be incidental and requires no further evaluation or treatment.
Collapse
|
|
35 |
16 |
13
|
Bernstein J, Monaghan BA, Silber JS, DeLong WG. Taxonomy and treatment--a classification of fracture classifications. THE JOURNAL OF BONE AND JOINT SURGERY. BRITISH VOLUME 1997; 79:706-7; discussion 708-9. [PMID: 9331019 DOI: 10.1302/0301-620x.79b5.7177] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
Review |
28 |
15 |
14
|
Abstract
There are many questions that remain to be answered regarding the evaluation, classification, and treatment of acetabulum fractures. Without a uniform classification and method of evaluation, a review of the literature can be misleading. Acetabular fractures represent an injury to the articular surface of a major weight-bearing joint and should be treated in accordance with the same criteria used for other intra-articular fractures.
Collapse
|
Review |
28 |
6 |
15
|
Born CT, Ross SE, Aron B, DeLong WG, Iannacone WM. Patterns of injury and disability caused by forklift trucks. THE JOURNAL OF TRAUMA 1996; 40:636-9. [PMID: 8614046 DOI: 10.1097/00005373-199604000-00020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Over a 7-year period, 34 patients were treated at the Southern New Jersey Regional Trauma Center for forklift-related injuries, ranging from minor contusions to multiple organ-system trauma. Hospital and rehabilitation courses were prospectively evaluated, documenting long term impairment of function and disability. Patients injured by falling from forklifts generally had less severe injuries, requiring fewer surgical procedures, shorter hospital stays, and less overall disability, than patients who received crush-type (object-oriented) injuries. The more serious injuries were most frequently caused by a forklift striking or running over the patient. There were strong correlations between the Injury Severity Score assessed upon initial evaluation and subsequent length of hospitalization, degree of disability, and extent of functional impairment after recovery. These findings support the enforcement of existing safety precautions for the operation of forklift trucks.
Collapse
|
|
29 |
5 |
16
|
Born CT, DeLong WG, Shaikh KA, Moskwa CA, Schwab CW. Early use of the Brooker-Wills interlocking intramedullary nail (BWIIN) for femoral shaft fractures in acute trauma patients. THE JOURNAL OF TRAUMA 1988; 28:1515-22. [PMID: 3184213 DOI: 10.1097/00005373-198811000-00001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
During a 33-month period, 40 multiply injured patients underwent 43 Brooker-Wills interlocking intramedullary nailings (BWIIN) for femur fractures in the setting of a Level I trauma unit. There were 12 open fractures (28%), 66% of the closed fractures underwent BWIIN within the first 24 hours of injury, and 33 fractures (77%) had comminution of Winquist-Hansen Type II or greater, and either static or dynamic locking techniques were used in 38 (88%) of the cases. There were three intraoperative technical problems. The estimated blood loss and operative times were consistent with other reported series for interlocking nailing techniques. The average followup was 65 weeks. Only one fracture went on to nonunion. There were no problems with angulation or rotation. One patient had 1.5 cm of shortening. There were four major (9%) and four minor (9%) complications. Rod removal was successful in 17 of 18 cases. Mechanical failure (deformation and/or fracture) of the proximal end of the rod was found in four (22%) of the extracted nails and caused failure of removal in one. The Brooker-Wills nail is a versatile device which can be used to treat complex fractures of the entire femoral shaft in acutely injured patients.
Collapse
|
|
37 |
4 |
17
|
Hewitt CW, Englesbe MJ, Tatem LD, Strande LF, Doolin EJ, Dalsey RM, DeLong WG. Graft-versus-host disease in extremity transplantation: digital image analysis of bone marrow in situ. Ann Plast Surg 1995; 35:108-12. [PMID: 7574277 DOI: 10.1097/00000637-199507000-00021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The development of either unstable immune chimerism and lethal graft-versus-host disease or stable immune chimerism and alloimmune tolerance can result from extremity transplantation. LBN rats served as recipients of Lewis vascularized extremity (limb) transplants. Recipients received no immune suppression and were immunologically unmodified. The bone marrow of transplanted and contralateral limbs was analyzed in situ for distribution of nuclei, nuclear area, and staining intensity by digital image analysis and computerized morphometry. Cellularity was significantly increased, and fat content was significantly decreased in the graft-versus-host disease animals' marrow versus the tolerant animals' marrow for both the transplanted and contralateral limbs. Tolerant animals demonstrated significantly increased nuclear staining compared with graft-versus-host disease animals for both transplanted and contralateral limbs. Additionally, there were significant changes between the host and the transplanted limbs for marrow intensity and cellularity within tolerant and graft-versus-host disease groups. The significant differences in the graft-versus-host disease-positive recipients suggested that both autoimmune dysregulation and alloimmune reactions were in effect for both donor and host bone marrow compartments. Cellular alterations in the tolerant recipients' marrow were suggestive of subtle subclinical graft-versus-host responses.
Collapse
|
|
30 |
4 |
18
|
Born CT, DeLong WG. Orthopaedic trauma education: visions for the future through the OTA. Orthopaedic Trauma Association. J Orthop Trauma 1999; 13:433-6. [PMID: 10459603 DOI: 10.1097/00005131-199908000-00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
As the trauma center system continues to expand, not only will the requirement for more and better trained trauma surgeons increase, but the means of educating them will need to become more standardized. The general surgeons recognized this many years ago, but orthopaedic trauma has lagged in its efforts to present a coordinated academic and clinical program to residents and fellows. The Orthopaedic Trauma Association has made a move to develop guidelines which may be used by training programs in an effort to improve the educational standards of this subspecialty. The recruitment and retention of young orthopaedic trauma surgeons remains an issue.
Collapse
|
|
26 |
3 |
19
|
Tatem LD, Hirpara S, Dalsey RM, Iannacone WM, DeLong WG, Hewitt CW. Role of in situ IL-2r and TGF-beta expression in tolerant vascularized bone marrow (limb) transplant chimeras. Transplant Proc 1997; 29:2194-5. [PMID: 9193586 DOI: 10.1016/s0041-1345(97)00292-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We hypothesized that an increase in IL-2 activated T cells in situ within the marrow component of a transplanted limb may adversely affect development of tolerance, while increased TGF-beta expression locally would facilitate tolerance induction and/or maintenance. Digital image analysis of cellular expression of IL-2r in the bone marrow was significantly increased in the CON and TXP limbs for both GVHD and tolerant recipients as compared to normal limb marrow (P < .02). The amount of cellular expression of TGF-beta was significantly increased in the GVHD animals, both CON and TXP, as compared to the tolerant animals (43.2 +/- 3.1 vs 10.6 +/- 2.6; P < .000001). Our results show that increased IL-2r and TGF-beta expression in situ within the bone marrow is an important effect common to both alloimmune tolerance and GVHD induction with VBMT chimeras. The dramatic increase in the expression of TGF-beta in the GVHD transplanted limbs may explain the profound immunosuppression that results. Additionally, moderate expression of TGF-beta in situ in tolerant chimeras may represent a mechanism for the induction and maintenance of tolerance.
Collapse
|
|
28 |
3 |
20
|
Born CT, Petrik M, Freed M, DeLong WG. Cerebrovascular accident complicating Klippel-Feil syndrome. A case report. J Bone Joint Surg Am 1988; 70:1412-5. [PMID: 3182899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
Case Reports |
37 |
|
21
|
Unkle DW, Armstrong JF, Ross SE, DeLong WG. Interpretation of the cervical spine X-ray: a simplified approach. Crit Care Nurse 1990; 10:48-51. [PMID: 2401158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Because many nursing interventions require mobilization of the patient, cervical spine film interpretation should be a necessary tool of the critical care nurse. This article provides the fundamentals necessary for initial interpretation of the cervical spine, plus a review of the common radiographic views of the cervical spine, abnormalities, and a systematic approach to the interpretation of these studies.
Collapse
|
|
35 |
|
22
|
Unkle D, DeLong WG. Abdominal trauma associated with pelvic fractures. Orthop Nurs 1989; 8:27-30. [PMID: 2668857 DOI: 10.1097/00006416-198907000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Abdominal trauma should always be suspected with major pelvic fractures until proven otherwise. Thorough assessment and diagnostic evaluation will determine whether surgical management is necessary. Nursing care continues to the postinjury period, which needs close observation because further complications are common.
Collapse
|
Review |
36 |
|
23
|
DeLong W, Grignon DJ, Eberwein P, Shum DT, Wyatt JK. Sarcomatoid renal cell carcinoma. An immunohistochemical study of 18 cases. Arch Pathol Lab Med 1993; 117:636-40. [PMID: 7684893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Malignant spindle cell neoplasms are a diagnostic challenge regardless of their location. In the retroperitoneum a major consideration in the differential diagnosis is sarcomatoid renal cell carcinoma; if an epithelial component cannot be recognized histologically, special studies may be required to reach the correct diagnosis. In an attempt to better characterize this entity, 23 cases of sarcomatoid renal cell carcinoma (6.3%) were identified from a review of 363 renal cell carcinomas. Blocks were available for immunohistochemical analysis in 18 cases. The epithelial and sarcomatoid portions were studied with a panel of antibodies directed against cytokeratin (AE1/AE3, CAM 5.2, and 34 beta E12), epithelial membrane antigen, Leu-M1, muscle-specific actin, S100 protein, desmin, and vimentin. The epithelial nature of the spindle cell component was best demonstrated by positive reactivity with the anti-cytokeratin AE1/AE3 (in 17 [94%] of the 18 cases). The other epithelial markers stained the spindle cell component less frequently: cytokeratin CAM 5.2 in seven cases (39%); epithelial membrane antigen in nine cases (50%); and high-molecular-weight cytokeratin 34 beta E12 in no cases (0%). In 10 cases (56%) vimentin positivity and in six cases (33%) actin positivity was seen in the spindled areas. The spindle cell component stained for Leu-M1 in four cases (22%) and for S100 protein in one case (6%) and did not react for desmin in any case. From this study we conclude that in the majority of sarcomatoid renal cell carcinomas the epithelial nature of the spindle cells, as indicated by cytokeratin expression, can be documented using immunohistochemical methods.
Collapse
|
|
32 |
|
24
|
Ramsamooj R, Llull R, Tatem LD, Black KS, Lotano V, Dalsey RM, Born CT, DeLong WG, Hewitt CW. Graft-versus-host disease in limb transplantation: digital image analysis of bone marrow and TGF-beta expression in situ using a novel 3-D microscope. Transplant Proc 1996; 28:2029-31. [PMID: 8769145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A subpopulation of parental to hybrid VBMT recipients developed characteristic clinical and histopathologic manifestations of GVHD. These changes are similar to those seen in human GVHD secondary to bone marrow transplantation. Human GVHD also manifests itself in an acute and chronic manner. Only a minority (30% to 40%) of animals developed lethal GVHD in our model. Those animals developing GVHD had a significantly (P < .0001) higher expression of TGF-beta in situ compared to the tolerant subpopulation. The differential expression of TGF-beta may represent an important mechanism of immune dysregulation associated with GVHD in CTA recipients.
Collapse
|
|
29 |
|