The arterial blood supply of the human patella. Its clinical importance for the operating technique in vascularized knee joint transplantations

1 This study aimed to assess the effect of cyclopiazonic acid (CPA), an inhibitor of sarcoplasmic reticulum calcium (Ca) pump, against contractile responses produced by selective tachykinin NK1 and NK2 receptor agonists, [Sar9]substance P (SP) sulfone and [beta Ala8]neurokinin A (NKA) (4-10), respectively, on the circular muscle of guinea-pig colon. All experiments were performed in the presence of atropine (1 microM) and indomethacin (10 microM). 2 In organ bath experiments, a submaximally equieffective concentration of the two agonists (10 nM) was selected: [Sar9]SP sulfone (10 nM) produced a biphasic contraction, the two amplitudes averaging 75 +/- 2 and 43 +/- 3% of the maximal response to KCl (80 mM) at 1 and 15 min from application of the agonist, respectively. CPA (3 microM for 60 min) slightly reduced the phasic response to [Sar9]SP sulfone (16 +/- 4% inhibition) and markedly suppressed the tonic component (89 +/- 3% inhibition). 3 The contraction produced by [beta Ala8]NKA (4-10) (10 nM) was more sustained than that induced by the NK1 receptor agonist: it averaged 69 +/- 5 and 73 +/- 4% of the response to KCl at 1 and 15 min from application of the agonist, respectively. CPA slightly and evenly depressed the response to [beta Ala8]NKA (4-10) (18 +/- 7 and 21 +/- 5% inhibition at 1 and 15 min). 4 In the presence of tachykinin NK1 and NK2 receptor antagonists (SR 140333 and MEN 10627, respectively, 1 microM each) and of L-nitroarginine (100 microM), KCl (40 mM) produced a distinct phasic and tonic contraction which was suppressed by 1 mM nifedipine. CPA (3 microM) did not affect the phasic contraction to KCl but abolished the tonic component of the response. 5 In the presence of 1 microM nifedipine, the response to [beta Ala8]NKA (4-10) was slightly depressed (32 +/- 6% inhibition) in its early component only, while the response to [Sar9]SP sulfone was abolished. CPA produced a slight inhibition (15 +/- 9 and 33 +/- 10% at 1 and 15 min, respectively) of the nifedipine-resistant response to [beta Ala8]NKA (4-10), an effect similar to that observed in the absence of nifedipine. Therefore, a large part of the response to [beta Ala8]NKA (4-10) persisted in the presence of both CPA and nifedipine. 6 In the sucrose gap, a prolonged superfusion with [Sar9]SP sulfone (0.1 microM for 5 min) produced sustained depolarization with superimposed spikes and contraction. CPA (3 microM) produced transient depolarization and contraction. In the presence of CPA, the initial responses (depolarization, spikes and contraction) to [Sar9]SP sulfone were unaffected but the sustained component of contraction was absent; the latter effect was accompanied by a suppression of spikes while the sustained depolarization was present. 7 We conclude that, during sustained depolarization produced by the NK1 receptor agonist, blockade of the sarcoplasmic reticulum Ca pump by CPA produces a faster Ca-dependent inactivation of Ca channels, thereby eliminating spikes and abolishing the tonic component of contraction. Ca mobilization/reuptake from a CPA-sensitive store seems to be of minor importance for regulating the NK2 receptor-mediated contractile responses.     

Importance of arterial blood supply to the femur and tibia for transplantation of vascularized femoral diaphyses and knee joints

The role of the periosteal and intraosseous blood supply to the femur and the proximal tibia was investigated to improve the operating technique for transplantation of allogenic vascularized femoral diaphyses and knee joints in humans. Altogether 48 limbs were injected with gelatin, red latex milk, or Revertex and macroscopically prepared; 41 limbs were studied for the variation and division of the truncus profundo-circumflexus. In 200 femurs and 200 tibias the location of the nutrient foramen was determined. The arteries supplying the periosteum of the distal femur and the proximal tibia have defined nutritive areas. The following technique should be followed: If the femoral artery alone is prepared as the vascular pedicle, the optimal section for resection of the femur in knee joint transplantations is 6 to 12 cm above the level of the femur condyles and 5 to 7 cm below the tibial plateau. For the transplantation of femoral diaphyses, the deep femoral artery can be used if the lateral femoral circumflex artery is protected. The Proximal line of resection is defined between the greater and lesser trochanter. For shorter grafts one must consider the number and location of nutrient foramens. For longer grafts the distal branches of the femoral artery must be respected as the intraosseous blood supply reaches distally down to the level of about 8 cm above the femoral condyles. In all these operations of the variation of the truncus profundo-circumflexus and the trifurcation of the popliteal artery must be considered.     

Allogeneic vascularized transplantation of human femoral diaphyses and total knee joints--first clinical experiences

This article has presented the preliminary results of three patients who received vascularized allogeneic femoral diaphyses and three patients having undergone vascularized transplantation of fresh and perfused total human knee joints. The large osseous defects in the femora followed osteomyelitis and chondrosarcoma. The three knee joints were lost due to various trauma mechanisms. All grafts were harvested within 25 hours from multiorgan donors perfused with 4 L of UW solution. All osteosyntheses were performed employing intramedullary nails. Vascular pedicles of the grafts were anastomosed end-to-side to the superficial femoral artery and vein in the adductorial canal of the recipient thigh. Immunosuppression was based mainly on two drugs: CyA and AZA. Perfusion of the grafts was demonstrated by DSA, and bone metabolism in the graft by SPECT scintigraphy. Six months after the operation all osteotomies demonstrated callus formation and osseous consolidation in conventional radiographs. Biopsies of the grafted bone revealed intact osteocytes, and arthroscopy of the transplanted knee joints demonstrated intact synovial, chondral, and ligamentous structures. From the surgical aspect, the vascularized transplantation of the femoral diaphyses and total knee joints is technically feasible. The main problems are immunologic. All transplantations were performed with respect to ABO compatibility, but with a large HLA mismatch. Therefore, acute and chronic rejection crises were observed. In total synovial joints, lifelong immunosuppression of graft recipients seems to be currently unavoidable.     

Allogeneic vascularized grafting of human knee joints under postoperative immunosuppression of the recipient

Vascularized knee joint transplantations have been performed in various animal systems. Up to now no allogeneic vascularized transplantation of a fresh and perfused human knee joint has been realized. This paper reports on the first four grafted human knee joints, performed between April 1996 and July 1997 at the Trauma Center Murnau. The indication for transplantation of a human knee joint is total loss of the joint, including the extensor apparatus, following severe trauma. Management of this defect is first to effect closure of the soft tissue defect combined with external transfixation and bone cement spacers. For the second phase the external stabilization is switched to internal stabilization using femoral tibial nails and a temporary knee joint prosthesis manufactured of polyethylene. The transplantations are performed with respect to ABO compatibility, ignoring the HLA system after a negative crossmatch. Osteosyntheses are employed by femoral and tibial nails. The vascular anastomoses are established in an end-to-side technique between the recipient's superficial femoral vessels and the graft vascular pedicles. Immunosuppression starts as quadruple induction therapy for 3 days. Subsequently it is reduced to a two-drug maintenance protocol with cyclosporin A and azathioprine. We utilize radiography, digital subtraction angiography, duplex sonography, scintigraphy, and arthroscopy for graft monitoring. Six months after transplantation the osteotomies were bridged with callus, and the patients were completely mobilized. The motion in the transplanted knee joint ranges from complete extension to 110 degree flexion.     

Development of extrahepatic arterial blood supply to the liver during hepatic arterial infusion chemotherapy

The aim of this study was to evaluate the correlation of development of the collateral circulation to the liver during hepatic arterial infusion chemotherapy (HAIC) with the presence of hepatic tumours adjacent to the hepatic surface, and with pretreatment occlusion of aberrant hepatic arteries. In 102 patients with unresectable malignant hepatic tumours treated with HAIC using an implantable port system, development of collaterals to the liver was assessed with CT arteriography using the implantable port and pre- and postoperative angiography. Aberrant hepatic arteries, if present, were occluded prior to treatment for hepatic arterial redistribution. Collaterals to the liver were seen in 29 patients, who had 35 areas with collateral perfusion: 22 areas were in the right posterosuperior area, 6 in the left peripheral area and 7 in the right or left lobar area. Collaterals were revealed more frequently in patients with hepatic tumours adjacent to the hepatic surface than in those without hepatic tumours in peripheral areas in the liver (p < 0.0001). In addition, collaterals developed more frequently in patients with an aberrant hepatic arterial anatomy compared with those with conventional anatomy (p = 0.0007). Our results indicated that patients with hepatic tumours adjacent to the hepatic surface and with pretreatment occlusion of aberrant hepatic arteries had the potential to develop collaterals to the liver during HAIC.     

The arterial supply of the developing proximal end of the human femur

By means of perfusion studies, an analysis was made of the arterial supply to the proximal end of the femur in 150 specimens from autopsied fetuses and children, aged from twenty-six weeks of gestation to fourteen years and eight months old. All died of diseases which did not involve the hip joint. Two anastomotic rings were found: an extracapsular one formed by the medial and lateral femoral circumflex arteries, and a subsynovial intra-articular ring at the articular cartilage-neck junction. The intra-articular rings in males were discontinuous more often than in females. A three-plane analysis of totally-cleared specimens demonstrated that the epiphyseal plate constituted an absolute barrier to blood flow between the epiphysis and metaphysis in all but two of the 124 barium sulphate-perfused specimens examined. A smaller number of ascending cervical arteries crossed the anterior and medial surfaces of the mid-neck in the specimens from three to ten-year-old white children than in those from newborn to two-year-old white and black children. This finding may be important for the etiology of Legg-Perthes disease. No differences with respect to age, sex, or race were found in the arteries of the ligamentum teres.     

Three-dimensional dynamic behaviour of the human knee joint under impact loading

Over the past 50 years, we have made remarkable advances in the use of bionic devices and solid organ transplants as replacement parts for failing tissues and organs. These approaches to tissue restoration, however, have a number of drawbacks. Thus, a new approach, regenerative biology and engineering, has been developed, consisting of the strategies of cell transplantation, bioartificial tissue constructs, and stimulation of regeneration in vivo. Cell transplants have been successfully used to restore articular cartilage and to treat Parkinson's disease in humans. In rats, transplanted fetal and embryonic stem cell line-derived cardiomyocytes have been shown to differentiate and integrate well with the ventricular myocardium, suggesting the feasibility of using such transplants to restore damaged cardiac muscle. Diabetic symptoms in humans have been alleviated by implanting a bioartificial pancreas consisting of islet cells microencapsulated in alginate. Hydroxyapatite matrixes can stimulate the regeneration of bone across large gaps. Collagenous artificial matrixes can stimulate the regeneration of dermis, and peripheral nerve grafts embedded in a fibrin clot containing fibroblast growth factor-1 stimulate some regeneration of spinal cord axons in adult rats. Future research in regenerative biology will focus on several issues: (1) providing adequate sources of cells for transplantation and bioartificial tissue construction and determining ways to prevent these cells from coming under attack by the immune system, (2) developing new and better materials to build better bionic devices and bioartificial constructs and to stimulate regeneration in vivo, (3) determining how many tissues of the body might contain reserve cells for regeneration in vivo, (4) analyzing the molecular differences between cells and environments of regenerating versus nonregenerating tissues, and (5) understanding the factors and mechanisms involved in the proliferation and patterning of regenerating tissues.     

Arthroscopy of the knee joint

A manual version and mechanized versions for several types of analyzers are described for the kinetic determination of glucose with glucose dehydrogenase. Results of glucose determinations with and without deproteinization of samples are discussed. The correlation of results with the hexokinase method is shown.     

Reconstruction of a congenital hypoplastic thumb with use of a free vascularized metatarsophalangeal joint

Reconstruction of a Blauth type-IIIB hypoplastic thumb with use of a free vascularized metatarsophalangeal joint was performed in four patients (four hands). Several tendon transfers also were performed, either primarily or secondarily, to mobilize the reconstructed thumb. Three patients (three hands) were followed for at least two years after the reconstruction; the results for these three patients were compared with those for four patients (six hands) who had been managed with pollicization of the index finger because of a similar deformity of the thumb. The patients were evaluated with regard to grip strength, key-pinch strength, and the range of motion of the joints of the thumb in the operatively treated and contralateral hands as well as with regard to skill in performing activities of daily living as assessed with use of the Kobe hand-function test. Although the appearance of the thumb was closer to normal in the group that had had the pollicization procedure, total function of the hand and grip strength were greater in the group that had had the transfer procedure. We believe that reconstruction of an unstable hypoplastic (Blauth type-IIIB) thumb with use of a vascularized metatarsophalangeal joint is an acceptable alternative to pollicization of the index finger.     

Total endoprosthesis of the knee joint

The results of conduction of 7 operations endoprosthetics of the knee joint using AGC-system of the "Biomet" concern are adduced. Details of operative procedure are enlightened, clinical cases and immediate results of operation are adduced.     

Anatomic orthotopic heart transplantation: the surgical characteristics and the advantages of the method

Standard technique of establishment of interatrial anastomoses allows to carry out orthotopic transplantation of the heart quickly and reliably. However the accumulation of collective experience evidences about a number of unavoidable shortcomings of such operation: rhythm disturbances, worsening of hemodynamics in discordant atrial contractions of recipient and donor, atrio-ventricular valve insufficiency, thromboembolism, coronary fistulas. Since 1990 in RRCS 25 operations were carried out with the use of standard technique and we also met with the risk of developing the above complications. In experiment on 30 mongrel dogs the technique of anatomical, truly orthotopic transplantation of the heart with six anastomoses was developed: left pulmonary veins with a common cuff, separate anastomoses of the superior and inferior caval veins, anastomoses of aorta and pulmonary artery. Particular attention was paid to developing of original surgical modes for prophylaxis of stenoses in the area of anastomoses of pulmonary and caval veins. In 1997 the anatomical technique of heart transplantation was successfully introduced by us into clinical practice. Clinical electrophysiological, echocardiographic and functional examinations have confirmed the results of the experiments and have evidenced for substantial advantages of the anatomical technique of orthotopic transplantation of the heart. By reliability the new operation is not inferior to standard method of N. Shumway.     

The arterial supply of the urinary bladder

(1) The urachal artery has a primary origin from the umbilical artery itself, and is at first bilateral. (2) The arterial pattern in newborn infants is not identical to that of adults. Obliteration of the umbilical artery in older infants carries with it obliteration of some of its branches, especially at their origin from its distal part, with a resulting change in arterial pattern. (3) The middle vesicle artery is a fairly constant branch of the umbilical artery, supplying the bladder neck and the front of the bladder above the neck. (4) The urachal and middle vesicle arteries, when unilateral, occur with equal frequency on both sides. (5) The anastomosis between superior vesical and inferior episgastric arteries was confirmed in the subperitoneal tissues, but was very rare in the wall of the bladder, occurring only when an abnormal obturator artery was the source of a superior vesical branch. (6) The constancy of the vesiculo-deferential artery is confirmed.     

Primary chronic polyarthritis of the knee joint

Rheumatoid arthritis is a chronic, multisystemic disease. The characteristic feature is persistent inflammatory synovitis. The knee joint is commonly involved with synovial hypertrophy, chronic effusion, and frequently ligamentous laxity. Pain and swelling behind the knee may be caused by extension of inflamed synovium into the popliteal space (Baker's cyst). Plain radiographs of the knee joint remain the basic radiological procedure, although early in the disease they might not provide significant changes. Sonography sufficiently reveals synovial fluid and Baker cysts, but cannot be recommended for evaluation of synovial proliferations or pannus formation. Computer tomography has only limited indications and may be used for the evaluation of subtle erosive lesions or the quantitation of osteoporotic changes. Magnetic resonance imaging has shown excellent visualization of cartilage, fluid, synovium and soft tissues and is the method of choice for the demonstration of early affection and the evaluation of pannus activity and therapy control. With administration of contrast agents (gadolinium), dynamic studies may demonstrate inflammatory activity. Modern MR sequences, such as T1 SE "fat sat" or magnetization transfer, further improve the discrimination of cartilage, pannus and synovial fluid.