Timothy Cooney

Maturity assessment and curve progression in girls with idiopathic scoliosis.

BACKGROUND Scoliosis progression during adolescence is closely related to patient maturity. Maturity has various indicators, including chronological age, height and weight changes, and skeletal and sexual maturation. It is not certain which of these indicators correlates most strongly with scoliosis progression. The purpose of the present study was to evaluate various maturity measurements and how they relate to scoliosis progression. METHODS Physically immature girls with idiopathic scoliosis were evaluated every six months through their growth spurt with serial spinal radiographs; hand skeletal ages; Oxford pelvic scores; Risser sign determinations; height; weight; sexual staging; and serologic studies of the levels of selected growth factors, estradiol, bone-specific alkaline phosphatase, and osteocalcin. These measurements were then correlated with the curve-acceleration phase. RESULTS The period and pattern of curve acceleration began during Risser stage 0 for all patients. Skeletal maturation scores derived with the use of the Tanner-Whitehouse-III RUS method, particularly those for the metacarpals and phalanges, were superior to all other indicators of maturity. Regression of the scores provided good estimates of maturity relative to the period of curve progression (Pearson r = 0.93). The initiation of this period occurred simultaneously with digital changes from Tanner-Whitehouse-III stage F to G. At this stage, curves also separated into rapid, moderate, and low-acceleration patterns, with specific curve types in the rapid and moderate-acceleration groups. The low-acceleration group was not confined to a specific curve type. CONCLUSIONS The curve-acceleration phase separates curves into various types of curve progression. The Tanner-Whitehouse-III RUS scores are highly correlated with timing relative to the curve-acceleration phase and provide better maturity determination and prognosis determination during adolescence than the other parameters tested. Accurate skeletal maturity determination should be used as the primary maturity measurement in girls with idiopathic scoliosis.

Correlates of the Peak Height Velocity in Girls With Idiopathic Scoliosis

Study Design. Prospective longitudinal. Objective. Determine correlates of the peak height velocity (PHV) in girls with idiopathic scoliosis. Summary of Background Data. Only identifiable retrospectively, the PHV is the most useful known maturity marker in idiopathic scoliosis. Clinically useful correlates are needed to make PHV timing helpful. Methods. A total of 24 immature girls with idiopathic scoliosis were followed with serial heights, sexual staging, skeletal ages, spinal radiographs, insulin-like growth factor (IGF)-1, IGF binding protein-3, dehydroepiandrosterone sulfate, estradiol, bone-specific alkaline phosphatase, and osteocalcin levels. These markers were correlated to PHV timing. Results. There were 14 girls who had identifiable growth peaks that averaged 10.5 ± 1.8 cm/y at age 11.7 ± 1 years. At the PHV, all girls were Risser 0 with open triradiate cartilages. On a skeletal age radiograph, digital uncapped phalangeal epiphyses were indicative of pre-PHV and fused epiphyses of post-PHV. Capped but unfused epiphyses were indeterminate. Tanner stage 1 for breast strongly indicates pre-PHV. Stage 3 for breast and pubic hair occurred at or after the PHV, and stage 4 always occurred after PHV. Higher IGF-1 and estradiol levels after PHV are potentially discriminatory. Conclusions. The PHV occurs during Risser 0 with open triradiate cartilages. If triradiate cartilages are open, then Tanner stages, IGF-1, estradiol levels, and the appearance of the epiphyses on a skeletal age radiograph are useful in determining status before or after PHV.

The relationship between serum relaxin and knee joint laxity in female athletes.

Gravidity studies have intimated a relationship between serum relaxin levels and joint laxity. To assess its applicability to eumenorrheic athletes, weekly serum relaxin and knee arthrometry measurements were obtained in 57 collegiate women and 5 men for 4 consecutive weeks. The former included athletes, ACL-injured athletes, and nonathletes, while the latter formed an a priori hormonal control. Analysis of variance revealed a significant change in weekly serum relaxin levels in females but not in anterior translation. Regression analysis failed to disclose a relationship between these variables. Therefore, we conclude relaxin does not affect knee laxity.

Innervation of the Labia Minora of Prepubertal Girls

INTRODUCTION Surgical and histologic sources of information give little reference to innervation, vascular, and epithelial details of the labia minora. Little is known about areas of nerve density, epithelial qualities, and vascular compartments of the labial minora that contribute to sexual arousal and orgasm. Surgical procedure development and counsel about surgical risks related to labioplasty and surgical flaps created from labial tissue may be based on inadequate information. METHODS Labial samples from 10 normal girls (aged 2-9 years) who underwent surgery for labial fusion utilized waste tissue strips for immunohistochemical identification of S-100 and neuronal nitric oxide synthase (nNOS) in the labia minora. RESULTS Vascular and lymphatic plexus lie within the reticular dermis, which contains a dense mesh of nerve fibers with a higher concentration of nerve fiber at the level of the subepithelial plexus. Dense innervations are located at the epidermis, extending along the basal and spinous layers of the epithelium of labia minora. Nerve bundles in the papillary dermis are associated with sebaceous and eccrine glands and nerve terminals located throughout the epithelium. The introital epithelium of the labia minora is highly innervated with widespread and intense staining, detected in the introital border of the labia minora versus the external one. The dermis appeared to display S-100 and nNOS immunolabelling. S-100 was also immunopositive in the epidermis. CONCLUSION Labia minora is highly innervated along its entire edge. Related vascular compartment tissue involved in engorgement during sexual arousal makes this tissue important for sexual response. Labioplasty risks removal of tissue with an important contribution to sensory sexual arousal. Movement of labial tissue during genitoplasty may have different sensory outcomes dependent on which labial surface is used.

Femoral remodeling may influence patient outcomes in slipped capital femoral epiphysis.

Clinical studies of patients treated for slipped capital femoral epiphysis have found limited functional impairment and femoral neck deformity causing eventual coxarthrosis. Since patient-focused assessments minimize bias and reflect health-related quality of life status, we coupled their use to a clinical examination to obtain a more patient-centered picture of slipped capital femoral epiphyseal outcomes. The impact of residual deformity on outcomes also was examined. Of 78 patients treated for slipped capital femoral epiphyses between 1972 and 1998, 29 (38 hips) were evaluated at a mean followup of 7.6 years (range, 1.4-26 years). The average patient age was 21.8 years (range, 14.6-39 years), 55% were female, and the average body mass index was 28.7 (range, 16.1-50.2). Most slips were stable (92%, 35 of 38) and mild or moderate in severity (98%, 36 of 37). Followup examinations revealed slight deficits in range of motion, strength, and limb length. Radiographs showed slight improvements in head-shaft angle and reduced but persistent femoral neck deformity. Osteoarthritic changes were absent or negligible in 84% (32 of 38) of the hips. The average Iowa hip score was 90.5 (range, 51-100). Patient outcome scores for the AAOS Hip/Knee Questionnaire fell slightly below 50th percentile norms. Neither slip stability, severity, nor body mass index impacted outcome. Femoral neck deformity correlated with function, pain, and Boyer grade. Overall, patients had minor functional deficits and pain that may have been related to femoral neck deformity, but longer followup is warranted.Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Immunohistological detection of relaxin binding to anterior cruciate ligaments.

Relaxin, a member of the insulin-like growth factor family, alters collagen metabolism in fibroblasts. It was hypothesized that relaxin interacts with the anterior cruciate ligament (ACL), contributing to its elasticity. Twelve ACL specimens were collected from reconstruction surgeries, sectioned, rinsed, and exposed to rh-relaxin overnight. Polyclonal antirelaxin antibodies, in conjunction with HRP-AEC, localized areas of tissue binding. Controls were used to infer binding specificity. Staining was present in the positive control and all 12 ACL specimens; little or no staining occurred in the negative controls. These data suggest that relaxin binding to the ACL is specific, indicative of a receptor-mediated event.

Relaxin's involvement in extracellular matrix homeostasis.

Burgeoning evidence suggests that the hormone relaxin modulates collagen in the extracellular matrix of diverse tissues. In separate lines of study, we provide further substantiation of this hypothesis. Immunofluorescence was used to probe isolated fibroblasts derived from volar oblique ligament explant culture for vimentin, actin, RXFP1, and estrogen receptor beta. Ligaments were obtained as surgical waste from thumb reconstruction patients. Four specimens have been examined to date. Cells derived from these patients expressed vimentin and actin, consistent with fibroblast morphology. Putative fibroblasts derived from two of three female patients expressed RXFP1 receptors; the solitary male was negative. Given the small sample, however, the data are considered preliminary. Immunohistochemistry was used on frozen sections from 26 skin biopsies obtained from children undergoing genitoplasty. A subset of samples was also probed for transforming growth factor (TGF‐β1) and TGF‐β3. Appropriate controls were used. Finally, a subset of patient blood was assayed for relaxin by using an enzyme‐linked immunosorbent assay‐based method. The results showed RXFP1 receptor expression in the cells that populate the basement membrane in 96% of patients, regardless of gender. Most tissue expressed TGF‐β. Finally, serology suggested that relaxin was detectable in these children. Our two lines of research provide additional evidence for the diverse tissue tropism of relaxin. In particular, connective tissues as diverse as ligaments and basal lamina keratinocytes express RXFP1. These data lend support to our contention that relaxin affects ligament integrity and wound healing.

The Impact of Loading on Deformation About Posteromedial Meniscal Tears

To simulate the effects of partial weight bearing on meniscal repair, full-thickness tears were produced in the posteromedial aspect of seven ACL-intact cadaveric knees. Following suture repair, metal markers were imbedded to index the position of the tear. A radiolucent chamber was used to position and load each knee for computed tomography scanning at flexion angles of 0 degrees, 30 degrees, and 60 degrees with and without a load force of 100 lb. Sutures were removed and the tests repeated. Changes in marker distances were obtained for each test condition. Loading produced average dimensional changes of < or =0.5 +/-0.6 mm in either sutured or unsutured menisci. Based on the Friedman test, neither flexion angle, loading, nor suture exerted a significant impact (P> or =.52). These data support clinical accelerated rehabilitation programs previously published. Therefore, partial weight bearing during convalescence is tenable.

Adequacy of Sanitization and Storage of Catheters for Intermittent Use After Washing and Microwave Sterilization

PURPOSE Clean intermittent catheterization is used to treat neurogenic bladders and it can be adequate to maintain sterile urine. Typically polyvinylchloride, individually packaged catheters are used but they are not intended for repeat use by the manufacturer. Antibacterial soap alone or combined with microwave heating was advocated to decrease pathogens and bacterial residue, which could inoculate the bladder from a colonized catheter. We assessed the efficacy of catheter sanitizing and storage for reuse. MATERIALS AND METHODS Catheters were inoculated with a 24-hour broth culture of Escherichia coli and washed in antibacterial soap, washed and microwaved or immediately packaged (positive controls) and stored for 1, 3 and 7 days, respectively. Common packaging was used, including paper towels, sealable plastic bags or sealable rigid plastic containers. Each condition was assessed in triplicate via culture of the entire catheter contents, yielding a total of 27 catheters per sanitization method. RESULTS Antibacterial wash alone failed to sanitize 67% of catheters (6 of 9 with 2 of 3 positive per container) on day 1, 22% (2 of 9 with all positive catheters in a paper towel) on day 3 and 44% (4 of 9 with 1 in a paper towel and 3 in a plastic container) on day 7. For combined antibacterial wash and microwave heating the positive rate was 0% (0 of 9 catheters) on day 1, 22% (2 of 9 in a plastic container) on day 3 and 56% (5 of 9 with 3 in a paper towel, 1 in a plastic bag and 1 in a plastic container) on day 7. Positive untreated controls showed viable organisms throughout the test period. CONCLUSIONS Overall 44% of catheters (12 of 27) washed with antibacterial soap yielded E. coli vs 26% (7 of 27) with combined antibacterial soap-microwave treatment. The latter is a more effective but not an absolute way to sanitize catheters for intermittent use. Longer storage time increased the risk of E. coli growth on the catheters.

In vitro analysis of periprosthetic strains following total knee arthroplasty.

Clinical case studies have disclosed certain risk factors associated with periprosthetic fracture in elderly patients. How the mechanical strength of the distal femur is changed by total knee arthroplasty (TKA) has not been elucidated. Using elderly cadaveric femora, this study evaluated both periprosthetic strains and associated fracture patterns arising from an in vitro simulation of a fall onto the distal femur. The data showed a significant increase in anterior and posterior mechanical strain following TKA. Neither stemless nor stemmed versions of two cemented Howmedica prostheses (Rutherford, NJ) reduced distal femur strains to baseline values. However, neither produced a disproportionate frequency of periprosthetic fractures. Although not formally evaluated herein, bone geometry/density may contribute more profoundly to the occurrence of periprosthetic fracture than the implants tested.