תוצאת חיפוש

Autologous Chondrocyte Transplantation - from Science Fiction to Routine Clinical Practice

Dror Robinson, Hana Ash, David Aviezer, Gabriel Agar, Nahum Halperin, Zvi Nevo

Dept. of Clinical Biochemistry, Sackler Medical School, Tel Aviv University, Ramat Aviv; Dept. of Orthopedic Surgery, Assaf Harofeh Medical Center, Zerifin; and CTI Ltd., Science Park, Kiriat Weizmann, Nes Ziona

Adult articular cartilage lacks the capacity for self-repair. The limiting factor appears to be the inability of chondrocytes to proliferate while embedded in the extracellular matrix typical of hyaline cartilage. Cartilage defects larger than 1 cm² change articular biomechanics and lead to eventual osteoarth-ritis and joint destruction.

During the past decade, several competing techniques have evolved to stimulate articular cartilage repair. Small lesions can be successfully treated by either micro-fracture or osteochondral cylinder grafting. The latter technique allows immediate weight bearing but leads to damage of previously uninvolved areas of articular cartilage, which limits its application to lesions of less than 2 cm².

When the damaged area is more extensive, grafting of autologous chondrocytes should be considered. First a diagnostic arthroscopy is performed to assess the damaged area and a small cartilage biopsy is taken. 6 weeks later, arthrotomy and chondrocyte transplantation are performed. In the interval, the antologous chondrocytes have expanded by 2 to 3 orders of magnitude. Our experience to date includes 10 cases with follow-up of 6 months to 5 years. Preoperative complaints of crepitation and locking disappear. There is functional improvement and pain reduction of approximately 50%. This procedure, currently limited to patients under 55 years of age with limited damage to an articular surface, for the first time allows reconstruction of damaged articular areas without resorting to allografts.

Spinal and Extra-Spinal Tumors Mimicking Discal Herniation

E. Tamir, Y. Mirovsky, D. Robinson N. Halperin

Orthopedics Dept., Assaf Harofeh Medical Center, Zerifin

Low back pain radiating to a limb is usually caused by lumbar disc herniation. Tumors of the spinal cord or near the sciatic or femoral plexus can cause neural compression and clinical signs similar to those of disc herniation. Such tumors are usually misdiagnosed as discal herniation and appropriate treatment is delayed. We present 4 men who had tumors causing low back pain radiating to the leg: a 70-year-old with metastatic squamous cell carcinoma of the lung, a 20-year-old with aneurysmal bone cyst of the vertebral column, a 52-year-old with retroperitoneal sarcoma and a 32-year-old who also had retroperitoneal sarcoma. Diagnosis and trwere delayed because the clinical symptoms were ascribed to lumbar disc herniation. The latter 2 patients had CT-scans showing lumbar disc herniation, but similar findings are common among asymptomatic individuals.

The differential diagnosis of low back pain radiating to the leg should include tumor when there is a history of cancer, pain not relieved by conservative treatment nor by lying down, pain is increased at night, pain accompanied by weight loss, and when physical examination demonstrates injury to more than 1 nerve root. In these circumstances work-up should include EMG, radioisotope scan and CT of the pelvis.

Severe Hypercalcemia Due to Renal Transitional Cell Carcinoma

D. Zamir, J. Weizman, N. Erlich, M. Amar, P. Weiner

Depts. of Medicine A, Urology and Pathology, Hillel Yaffe Medical Center, Hadera

Hypercalcemia is a common metabolic disorder, especially in the elderly. The most common etioloare hyperparathy-roidism or malignancy, most often of the lung, breast, kidney or hematological system. Because hypercalcemia is an uncommon manifestation in urinary tract epithelial tumors, especially those of the renal pelvis, we present a man aged 62 years with hypercalcemia due to renal transitional cell carcinoma.

Propafenone Dose for Emergency Room Conversion of Paroxysmal Atrial Fibrillation

D. Antonelli, A. Darawsha, S. Rimbrot, N.A. Freedberg, T. Rosenfeld

Dept. of Cardiology and Emergency Room, Central Emek Hospital, Afula

Paroxysmal atrial fibrillation (AF), a frequent cause of repeated hospitalization, is effectively treated with propafenone. The time to conversion to sinus rhythm is a consideration when managing AF in the emergency room. We investigated the conversion rates of paroxysmal AF by 3 different oral propafenone (P) regimens, in terms of time to conversion.

188 patients with onset of AF within 48 hours were treated with propafenone (P): 48 received 600 mg as a first oral dose followed after 8 hrs by 150 mg (Group A); 82 received 300 mg as a first dose, followed by the same dose 3 and again 8 hrs later (B); 58 received 150 mg every 3 hrs, up to a total dose of 600 mg (C). P was stopped when sinus rhythm was achieved.

Rates of conversion to sinus rhythm after 3 hrs in the 3 groups were: 46%, 41% and 26% respectively; after 8 hrs: 77%, 78% and 70%; and after 12 hrs: 81%, 84% and 76%. Treatment was discontinued in 8. There was excessive QRS widening (>25% of the basal value) in 1 in group A, 1 in group B and 2 in group C; wide-QRS tachycardia occurred in 4 in group B. In Group A there was a higher rate of early successful conversion, with a lower incidence of side-effects than with the other regimens.

Retroperitoneoscopic Lumbar Sympathectomy

D. Seror, O Zamir, D. Eimerl, H.R. Freund

Depts. of Surgery and Anesthesia, Hadassah University Hospital, Mount Scopus and Hebrew University-Hadassah Medical School, Jerusalem

We present our initial experience with retroperitoneoscopic lumbar sympathectomy in a series of 5 men aged 25-45 years. 3 suffered from ischemia of the lower limbs due to Buerger's disease, 1 had severe reflex sympathetic dystrophy and 1 had vasculitis with severe, non-healing lower leg ulcers.

The right retroperitoneal space was developed with a dissecting balloon-trocar introduced via a small lateral muscle- splitting flank incision. 2 additional 5 mm trocars were used for instrumentation and clipping. L2-L3 or L3-L4 ganglia were resected; mean operating time was 120 minutes. Only oral analgesics were needed for postoperative pain control and oral food intake was resumed the following morning. The procedure was successful in all and was without complications. Mean hospital stay was 2 days.

All patients reported significant relief of ischemia or dystrophic pain and/or improvement in trophic changes in the extremities. In the patient with leg ulcers, the largest was successfully covered with a skin graft. The retroperitoneoscopic approach to lumbar sympathectomy successfully combines the advantages of minimal invasive surgery and the reliability and effectiveness of well-established open sympathectomy.

Epidural Spinal Abscess

E. Tamir, Y. Mirovsky, N. Halperin

Orthopedics Dept., Assaf Harofeh Medical Center, Zerifin

A 42-year-old man was admitted for fever and severe low back pain radiating to both legs. On MRI, an epidural spinal abscess from S1 to D10 was seen. Treatment included laminectomy, drainage of the abscess and antibiotics. Recovery was complete without neurological damage. Increased awareness of this disease may lead to diagnosis and treatment.

Osteoid Osteoma of the Hand: a Rare Location

Nahum Rosenberg, Shalom Stahl

Dept. of Orthopedics A, and Hand Surgery Unit, Rambam Medical Center, Haifa

Osteoid osteoma is a benign bone tumor. It is rare in the hand where it may cause local swelling and pain. Marginal resection is almost always curative, without residual functional disability. Because it is rare in this location, osteoid osteoma is not usually considered in the differential diagnosis of painful lesions of the hand, which may delay treatment. Osteoid osteoma in the hand has characteristic clinical, roentgenologic and scintigraphic features. Early diagnosis of this lesion may be improved by recognition of these features. An algorithm for decision-making that may help is proposed. We describe our experience in 3 cases involving, respectively, the capitate bone, a proximal, and a distal phalanx, in which cases marginal resection was curative.

Technetium 99-M Sestamibi Bone Scan in Musculo-Skeletal Neoplasms

Dror Robinson, Lena Pinkas, Lilia Mindlin, Nahum Halperin, Tifha Horn

Dept. of Orthopedics and Nuclear Medicine, Assaf Harofeh Medical Center, Zerifin

It is often difficult to assess accurately the nature of a skeletal lesion. Problems include differentiating a malignant from a benign bone tumor, as well as determining the cause of a pathologic fracture. Such fractures may occur through osteoporotic bone as well as through neoplasm-affected bone. Thus, development of an imaging modality capable of distinguishing between such lesions is of importance. During 1996, we ran a prospective study in which results of Tc-99m-methyl-diphosphate (MDP) bone scans were compared with those of sestamibi (MIBI) bone scans and with subsequent biopsy and clinical course. The results of the bone scans were assessed by 2 independent "blinded" observers, and the ratios of counts in lesions to those in normal tissue (L/N ratios) were calculated. In cases of malignant (7) and benign (8) tumors, intensity of uptake in MDP scans were not predictive of degree of aggressiveness. On the other hand, MIBI bone scans demonstrated significant difference in intensity of uptake between benign and malignant bone tumors (L/N ratios 2.05 vs 2.75). In 5 of 8 benign lesions the L/N ratio was 1. In the others, increased uptake was minimal. In 2 patients changes in uptake in MIBI bone scan following chemotherapy appeared to be related to the degree of tumor necrosis achieved. While the MIBI bone scan cannot replace tissue biopsy as a definitive diagnostic modality in bone neoplasms, it does appear to allow better preoperative assessment and prognosis.

Acute Fungal Endocarditis Due To Trichosporon Beigelli

Nahum Nesher, Alon Erez, Doron Nezer, R. Finkelstein, Y. Barel

Dept. of Cardiac Surgery, Rambam Medical Center, Haifa and Technion Faculty of Medicine

We report a 59-year-old woman with acute fungal endocarditis of a prosthetic valve caused by the endogenic organism, Trichosporon beigelli. This slowly developing disease mainly effects drug addicts who use intravenous narcotics. In nonaddicts it is rare, with mortality as high as 50%. There are only sporadic reports of T. beigelli as a complication long after open heart surgery. The ongoing infection is undetected for even several years after the primary infection, due to its prolonged latent phase. We present the difficulties of diagnosis, and of treating the disease with a combination of surgery and of long-term chemotherapy.