Capsular Adhesions Research Articles

Wegener Granulomatosis with Spleen Infarction: Case Report and Review of the Literature

To report a case of biopsy-verified Wegener granulomatosis (WG) with positive c-antineutrophil cytoplasmic antibodies who had evidence of spleen infarction and to review the relevant literature on spleen involvement in WG. Descriptive case report of 1 patient with WG complicated by spleen infarction and review of the relevant literature (PubMed search 1966 through February 2007). In our patient spleen involvement (infarction) was clinically silent and was incidentally detected on the caudal slides of a chest computed tomography (CT) performed to investigate pulmonary involvement. Similar cases have been reported: in the published literature reviewed, overall 18 patients have been described and other cases have been described after autopsy. Of these, 8 patients were symptomatic: generally, they complained of diffuse or left upper quadrant abdominal pain. In 15 patients, spleen involvement was detected by ultrasound, scintigraphy, CT scan, or magnetic resonance imaging. In 1 case only was the diagnosis confirmed by biopsy (after splenectomy). The frequency of spleen infarction is probably underestimated in WG since it is often clinically silent as in our patient. In addition to spleen infarction, WG has also been implicated in inducing spleen hemorrhage, capsular adhesions, dysfunction, and splenomegaly. Since some of the spleen lesions may lead to complications, a high index of suspicion should be maintained for spleen involvement in patients with WG, particularly in the presence of abdominal symptoms.

Predictors of long-term outcome of children with idiopathic focal segmental glomerulosclerosis

Clinical and histological data of children presenting with steroid-resistant nephrotic syndrome and renal biopsy showing focal and segmental glomerulosclerosis from 1980 with a follow-up of over 10 years were reviewed. There were 66 patients; 38 male and 28 female. Age at onset ranged from 0.4-14.1 years (mean 6.4). Tubular atrophy was present at first biopsy in 50/66, capsular adhesions in 35/66, glomerular tip lesions in 8/66 and mesangial expansion in 31/66 patients. In 51 children, cyclophosphamide was prescribed as the first cytotoxic agent, while 15 received cyclosporine A and complete remission was induced in 43 and 40% of the children, respectively. Complete and stable remission was maintained in 35 children, while 22 had reduction of proteinuria with symptomatic relief. Nine were refractory to cytotoxic therapy. Of the 35 patients who entered complete and stable remission, the renal survival was over 90%, while in the 31 non-responders it was 48% in 10 years. The multivariate analysis using unconditional logistic regression method identified the presence of mesangial expansion (p=0.011) and tip lesions (p=0.005) as the independent predictors of favourable response to cytotoxic therapy and the presence of renal impairment (p=0.008) and extensive focal segmental sclerosis (p=0.025) as independent predictors of unfavourable response.

Podocyte Depletion Causes Glomerulosclerosis

Glomerular injury and proteinuria in diabetes (types 1 and 2) and IgA nephropathy is related to the degree of podocyte depletion in humans. For determining the causal relationship between podocyte depletion and glomerulosclerosis, a transgenic rat strain in which the human diphtheria toxin receptor is specifically expressed in podocytes was developed. The rodent homologue does not act as a diphtheria toxin (DT) receptor, thereby making rodents resistant to DT. Injection of DT into transgenic rats but not wild-type rats resulted in dose-dependent podocyte depletion from glomeruli. Three stages of glomerular injury caused by podocyte depletion were identified: Stage 1, 0 to 20% depletion showed mesangial expansion, transient proteinuria and normal renal function; stage 2, 21 to 40% depletion showed mesangial expansion, capsular adhesions (synechiae), focal segmental glomerulosclerosis, mild persistent proteinuria, and normal renal function; and stage 3, >40% podocyte depletion showed segmental to global glomerulosclerosis with sustained high-grade proteinuria and reduced renal function. These pathophysiologic consequences of podocyte depletion parallel similar degrees of podocyte depletion, glomerulosclerosis, and proteinuria seen in diabetic glomerulosclerosis. This model system provides strong support for the concept that podocyte depletion could be a major mechanism driving glomerulosclerosis and progressive loss of renal function in human glomerular diseases.

Arthroscopic-Assisted Surgical Treatment for Developmental Dislocation of the Hip

Treatment of developmental dislocation of the hip (DDH) includes surgical management in older children or in those who cannot be treated conservatively. However, complication rates of surgical treatment are quite high. The purpose of this report is to introduce our new surgical technique that can eliminate existing pathologic changes in DDH. A small case series. We performed arthroscopic-assisted surgical treatment in 4 hips of 4 female children who had DDH and no previous treatment. Their ages ranged from 11 to 14 months. Closed reduction under general anesthesia was tried just before the surgical intervention, but it failed in all of them. Tightness of the iliopsoas tendon was released followed by dissection of capsular adhesions using an anterolateral mini-incision. Excision of the hypertrophic ligamentum teres, transverse acetabular ligament, and pulvinar tissue was carried out using a double-portal arthroscopic procedure. We performed percutaneus adductor tenotomies in 2 cases. A spica cast and abduction splint were used for 12 to 17 weeks postoperatively. The follow-up of the patients was a minimum of 1 year. Although a 1-year follow-up period is adequate to evaluate the short-term results, it has been considered that there is a need for further studies that include long-term follow-up. We used the acetabular index and Shenton's line for preoperative and postoperative radiologic evaluation. Also, the cases were evaluated postoperatively in respect to range of motion restriction and the leg length discrepancy. The mean follow-up was 13.7 months (range, 12 to 16 months). Acetabular index measurements of the cases in the preoperative/postoperative periods were as follows: in the first case, 34 degrees/27 degrees; in the second case, 35 degrees/22 degrees; in the third case, 52 degrees/39 degrees; and in the fourth case, 40 degrees/28 degrees. Hip joint restriction and leg length discrepancy were not observed postoperatively. All the intra-articular structures (hypertrophic ligamentum teres, transverse acetabular ligament, and pulvinar tissue) in the acetabulum that impede the reduction of the femoral head have been eliminated by using the arthroscopic technique. The arthroscopic-assisted surgical treatment of DDH is successful in the short-term follow-up period. Level IV, Case Series.

Natural history of idiopathic IgA nephropathy and factors predictive of disease outcome

Among the numerous studies published in the last 20 years that have calculated the actuarial renal survival and tried to individuate the prognostic role of the clinical and histologic features present at the onset of the disease or the time of biopsy, we chose to critically analyze the results of the most valid (23 studies). Actuarial renal survival at 10 years in adults was between 80% and 85% in most of the European, Asian, and Australian studies, but was lower than this in studies from the United States and exceeded 90% in the few studies on children. Concordance existed in this selected literature on the fact that impairment of renal function, severe proteinuria, and arterial hypertension are the strongest and more reliable clinical predictors of an unfavorable outcome. Extent of proteinuria during follow up was an even stronger predictor. In adult patients, a high score of the glomerular and tubulointerstitial lesions predicted a more rapid progression. When the single lesions were analyzed separately, glomerular sclerosis and interstitial fibrosis appeared to be the strongest, most reliable predictors of unfavorable prognosis. More controversial was the role of crescents and capsular adhesions.

Fixed flexion deformity of the knee following femoral physeal fracture: the Inverted Cyclops lesion

An adolescent inter-condylar fracture of the distal femur was treated with percutaneous cancellous screws and an above-knee plaster. The subsequent fixed flexion deformity of the knee was initially considered to be due to soft tissue capsular scarring and adhesions but arthroscopic assessment of the joint identified an ‘Inverted Cyclops’ lesion. This consisted of excess callus and fibrous tissue arising from the femoral notch. Arthroscopic excision of this tissue cured the deformity.

Natural history of idiopathic IgA nephropathy: Role of clinical and histological prognostic factors

Idiopathic immunoglobulin A nephropathy is characterized by an extreme variability in clinical course and sometimes by the unpredictability of the ultimate outcome. Among the numerous studies published in the last 15 years that have calculated the actuarial renal survival and tried to individuate the prognostic role of the clinical and histological features present at the onset of the disease or the time of biopsy, we chose to analyze critically the results of the most valid (30 studies). Actuarial renal survival at 10 years in adults was between 80% and 85% in most of the European and Asian studies, but it was less in studies from the United States and exceeded 90% in the few studies of children. Concordance existed in this selected literature that impairment of renal function, severe proteinuria, and arterial hypertension are the strongest and more reliable clinical predictors of an unfavorable outcome. However, analysis of the prognostic value of morphological lesions was more difficult because they have been characterized in some studies using an overall score or histological classes of progressively more severe involvement and, in others, using a semiquantitative grading of individual glomerular, tubular, interstitial, and vascular changes. In adult patients, a high score of glomerular and tubulointerstitial lesions, corresponding to classes IV and V of the Lee or Haas classifications, predicted a more rapid progression. When single lesions were analyzed separately, glomerulosclerosis and interstitial fibrosis appeared to be the strongest, most reliable predictors of unfavorable prognosis. More controversial was the role of crescents and capsular adhesions. None of the immunohistological features was found to be a risk factor for progression in the more accurate statistical analyses. The same histological features predicted outcome in children, although the severity of lesions at the time of biopsy was usually less than that in adults. However, in the single patient, even the evaluation of these prognostic markers sometimes fails to correctly predict outcome, probably because of the heterogeneity of the disease and the discontinuous activity of some injuring mechanisms during its course.

ACE gene polymorphism in childhood IgA nephropathy: association with clinicopathologic findings.

A deletion polymorphism in the angiotensin-converting enzyme (ACE) gene has been reported to be a risk factor for progression to chronic renal failure in immunoglobulin A nephropathy (IgAN). In this study, we investigated the association between ACE gene polymorphism and clinical findings, early biopsy findings such as the extent of mesangial proliferation, focal lesions (capsular adhesions, glomerulosclerosis, and crescents), and the glomerular area in childhood IgAN. Genomic DNA was obtained from 97 patients and control subjects. Gene polymorphisms, consisting of an insertion (I) or deletion (D) of the 287-base pair Alu sequence, were detected using the polymerase chain reaction. The extent of capsular adhesions and glomerulosclerosis was significantly higher in patients with the ID/DD genotypes than in those with the II genotype (ID/DD v II: 8.0%+/-1.4% v 2.5%+/-0.8% [P = 0.017] and 5.1%+/-1.3% v 1.4%+/-0.6% [P = 0.028], respectively). Whereas there was no difference in the extent of mesangial proliferation and crescents between the ID/DD genotypes and the II genotype. Urinary protein excretion at the time of biopsy was significantly greater in patients with the ID/DD genotypes than in those with the II genotype (1.02+/-0.15 g/d/m2 body surface area v 0.56+/-0.13 g/d/m2 body surface area; P = 0.012). These results indicate that ACE gene polymorphism may not influence the extent of mesangial proliferation and crescents that are acute lesions. However, the ID/DD genotypes are associated with chronic lesions, such as capsular adhesions or glomerulosclerosis and urinary protein excretion in childhood IgAN.

Podocytes undergo phenotypic changes and express macrophagic-associated markers in idiopathic collapsing glomerulopathy

Podocytes undergo phenotypic changes and express macrophagic-associated markers in idiopathic collapsing glomerulopathy

Can immunosuppressive drugs slow the progression of IgA nephropathy?

The role of immunosuppressive drugs in the treatment of IgA nephropathy (IgAN) remains controversial. The effect of treatment with prednisolone and azathioprine on the clinical course of patients with IgA nephropathy is described in this retrospective study. One hundred and fourteen patients, 66 treated (age 13-77 years) and 48 untreated (age 15-64 years), were evaluated. The two groups of patients differed significantly with respect to heavier proteinuria (median 3.6 g/day, range 0.2-18 g/day), lower serum albumin level (< 40 g/l) and more severe renal histopathological involvement in the treated group (P < 0.01). Oral prednisolone 40 mg/day and azathioprine 2 mg/kg BW/day was commenced initially and after gradual tapering was continued at low dose (5 mg/day) for a median duration of 24 months (range 12-98). The median duration of follow-up was 46 months (range 12-180). The clinical course was defined as progressive or non-progressive on the basis of serial serum creatinine (Scr). Of the patients who presented with renal impairment (Scr > 110 mumol/l), a non-progressive course was observed in 79.5% patients of the treated group (n = 39), while only in 36% of the untreated group (n = 22), the difference was statistically significant (P < 0.001). Slopes of reciprocal of Scr versus time were also calculated by linear regression analysis to represent the trend of renal function for patients who had had 3 or more years follow-up (n = 101). An analysis of variance of these trends in patients with renal impairment at presentation (n = 51) showed significant recovery of renal function in the treated group (n = 33) and a decline of renal function in the untreated group (n = 18, P = 0.004). There was no significant effect of the treatment on proteinuria. The histopathological features that favoured response to the treatment were mesangial proliferation, capsular adhesions and interstitial infiltration on light-microscopy, C3 and fibrin deposits on immunofluorescence (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Insudative lesions—Their pathogenesis and association with glomerular obsolescence in diabetes: A dynamic hypothesis based on single views of advancing human diabetic nephropathy

Kidneys from 74 consecutive, primarily non-insulin-dependent diabetics at autopsy and 59 age-, sex-, and ethnic group-matched controls were examined qualitatively and semiquantitatively to determine the prevalence and severity of insudative lesions (ILs) and obsolescent glomeruli with (OG c FC) and without (OG s FC) insudative (fibrin cap) lesions. A subset of 25 cases with advanced diabetic changes was examined using serial sections, immunohistochemical stains, and electron microscopy to determine the pathogenesis of ILs and OG c FCs. Insudative lesions consisted of intramural accumulations (hereafter called deposits) of presumably imbibed plasma proteins and lipids within renal arterioles, glomerular capillaries, Bowman's capsule, and proximal convoluted tubules. Insudative lesions in Bowman's capsule are called capsular drop lesions (CDs), in glomerular capillaries they are called fibrin cap lesions (FC), and in afferent and efferent arterioles they are called hyalinized afferent (HA) and hyalinized efferent (HE) arterioles, respectively. All ILs were much more numerous and/or larger in diabetics than in controls. Contrary to previous opinion, CDs and HE arteioles were not specific for diabetes, being present in small numbers in nine (15%) controls. Controls with CD HE arterioles had far more HA arterioles and focal mesangiolyses (FMs) than those without. Insudative lesions consisted of the well known homogenous eosinophilic deposits (homogenous eosinophilic ILs) and the less familiar foamy, reticulated, and vacuolar deposits (heterogenous lucent ILs). Homogenous eosinophilic ILs were predominant in afferent arterioles and more so in efferent arterioles, and were segregated into globules of varying density with the denser deposits located peripherally. Two types of CDs, which differed sharply in location and composition, were found. The first was mostly homogenous eosinophilic, usually without capsular adhesions and located near the vascular pole close to preglomerular arterioles. The second was mostly heterogenous lucent, located away from the vascular pole, and consistently connected by adhesions to the capillary tuft usually near FMs and/or Kimmelstiel-Wilson (KW) nodules. The latter ILs sometimes extended in continuity along the internal surface of the basement membrane from Bowman's capsule into the proximal convoluted tubule. It was hypothesized that ILs traveled centrifugally through the walls of preglomerular arterioles to form the first type of CD and longitudinally within the walls of afferent arterioles and glomerular capillaries and through adhesions to form the second. Contrary to previous opinion, FCs were consistently intramural. When numerous, FCs were associated with a form of glomerular obsolescence called OG c fc. Obsolescent glomeruli with fibrin cap lesions had patent circulations (a significant percentage of patententering arterioles and red blood cell [RBC]-containing capillaries), slightly more than 50% of FCs by volume, relatively mild tuft collapse, and considerably decreased nuclei without glomerular necrosis. It was hypothesized that OG c FCs were caused by capillary luminal compression by migrating intramural FCs. Obsolescent glomeruli with fibrin cap lesions were increased in all diabetic cases (2.38% ν 0.26% in controls; P = .0029) but were most numerous in those diabetics with proteinuria (7.1%), mild to moderate renal insufficiency (17%), and end-stage renal disease (28.3%). Obsolescent glomeruli with fibrin cap lesions appreared to develop relatively rapidly, possibly under the influence of hemodynamic factors. Therein lies their potential importance, ie, common lesions capable of producing glomerular destruction that may respond to manipulation of hemodynamic or other factors.

Probucol Reduces Renal Injury in the ExHC Rat

To investigate the potential roles of oxidized lipoproteins and glomerular macrophages in the pathogenesis of lipid-induced glomerular injury, we examined the effects of administration of probucol on the development of renal injury in ExHC rats. ExHC rats are derived from the Sprague-Dawley strain and are highly susceptible to dietary hypercholesterolemic stimuli. We reported previously that ExHC rats fed a cholesterol-supplemented diet (HCD) develop proteinuria and characteristic glomerular lesions. These lesions include marked accumulation of numerous lipid-filled foam cells, which have a surface marker that identifies them as macrophages, within mesangial regions, as well as segmental clusters of foam cells that are associated with capsular adhesions, the destruction of glomerular tufts and glomerular sclerosis. ExHC rats were maintained on an HCD or on an HCD supplemented with 5% (wt/wt) probucol for 8 weeks. Probucol reduced the extent of renal injury, as evidenced by proteinuria and segmental glomerular lesions, in ExHC rats fed an HCD, in the absence of any significant reduction in plasma cholesterol levels. Both low-density lipoprotein and beta-very-low density lipoprotein isolated from the plasma of probucol-treated rats were found to be resistant to oxidative modification by cupric ions. Both the size and the number of foam cells within glomeruli in the probucol-treated rats were significantly reduced as compared to those of foam cells in the untreated rats. Probucol might reduce renal injury in ExHC rats by limiting the oxidative modification of lipoproteins and, subsequently, by restricting the foam cell transformation of macrophages within glomeruli and by inhibiting the recruitment of macrophages into glomeruli. The results of the present study may be interpreted to indicate that local glomerular oxidative modification of lipoproteins might occur in vivo, and both oxidized lipoproteins and glomerular macrophages may play important roles in the pathogenesis of lipid-induced glomerular injury.

Schönlein-Henoch nephritis and IgA nephropathy in children.

When Schönlein-Henoch nephritis presents with more than just microhematuria, only 72% of cases go on to complete recovery. Evidence of renal disease may reappear after apparent complete recovery. Schönlein-Henoch nephritis may be the single commonest form of crescentic glomerulonephritis, accounting for 30% of cases. Prednisone for 2 weeks may prevent Schönlein-Henoch nephritis in children who do not already have it when first seen. IgA nephropathy was found in 8% of children with isolated proteinuria and has been reported with human immunodeficiency virus infection. Heavy proteinuria at onset, focal sclerotic and tubulointerstitial changes, and crescents and capsular adhesions are poor prognostic indicators. The prognostic significance of hypertension and of the absence of gross hematuria remains uncertain. After a follow-up of at least 8 years, 53% of patients are clinically in remission. In a short-term double-blind, crossover trial, prednisone had no effect on IgA nephropathy. Recent advances do not yet lead to a unifying concept of the pathogenesis of Schönlein-Henoch nephritis or IgA nephropathy.

Adjuvant therapy with intraperitoneal chromic phosphate ( 32P) in women with early ovarian carcinoma after comprehensive surgical staging

From 1974-1990, 23 women with stage I and five with stage II epithelial ovarian carcinoma received intraperitoneal chromic phosphate (32P) as the only form of adjuvant therapy after complete debulking and comprehensive surgical staging laparotomy. Surgery consisted of total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, peritoneal washings for cytology, multiple biopsies of pelvic and abdominal peritoneum, and selective pelvic and para-aortic lymphadenectomy. Intraperitoneal 32P therapy was administered a median of 7 days after laparotomy. Significant toxicity was minimal; none of these patients required surgery for bowel obstruction. Overall 5-year survival was 90 and 100%, but disease-free survival was only 65% (95% confidence interval [CI] 36-86%) and 60% (95% CI 12-81%) for patients with stage I and II disease, respectively. Two patients developed intraperitoneal and six systemic relapses; all patients received cisplatin regimens after relapse. Univariate analysis of age, stage, histology, Ovarian Cancer Study/Gynecologic Oncology Group risk status, lesion size, and presence or absence of capsular adhesions revealed that only an age of 50 or more years had an adverse effect on disease-free survival (P less than .03). This study suggests that determination of early-stage disease and host-tumor biology may be the most important factors in determining the survival of women with early ovarian cancer defined by comprehensive surgical staging. Intraperitoneal 32P does not appear to be effective adjuvant therapy in these women.

Adjuvant therapy with intraperitoneal chromic phosphate ( 32P) in women with early ovarian carcinoma after comprehensive surgical staging

From 1974-1990, 23 women with stage I and five with stage II epithelial ovarian carcinoma received intraperitoneal chromic phosphate (32P) as the only form of adjuvant therapy after complete debulking and comprehensive surgical staging laparotomy. Surgery consisted of total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, peritoneal washings for cytology, multiple biopsies of pelvic and abdominal peritoneum, and selective pelvic and para-aortic lymphadenectomy. Intraperitoneal 32P therapy was administered a median of 7 days after laparotomy. Significant toxicity was minimal; none of these patients required surgery for bowel obstruction. Overall 5-year survival was 90 and 100%, but disease-free survival was only 65% (95% confidence interval [CI] 36-86%) and 60% (95% CI 12-81%) for patients with stage I and II disease, respectively. Two patients developed intraperitoneal and six systemic relapses; all patients received cisplatin regimens after relapse. Univariate analysis of age, stage, histology, Ovarian Cancer Study/Gynecologic Oncology Group risk status, lesion size, and presence or absence of capsular adhesions revealed that only an age of 50 or more years had an adverse effect on disease-free survival (P less than .03). This study suggests that determination of early-stage disease and host-tumor biology may be the most important factors in determining the survival of women with early ovarian cancer defined by comprehensive surgical staging. Intraperitoneal 32P does not appear to be effective adjuvant therapy in these women.

Prognostic Indicators in Childhood IgA Nephropathy

A number of clinical, laboratory and pathologic parameters were assessed for their prognostic significance in 200 children aged less than 15 years with IgA nephropathy, who had shown normal renal function at the time of initial biopsy and were followed for more than 2 years thereafter. After a mean follow-up period of 5.0 years from the initial biopsy, 93 patients had no demonstrable abnormality, 76 had minor urinary abnormalities, 21 had persistent heavy proteinuria and 10 had developed chronic renal impairment. A poor outcome was found to be correlated with heavy proteinuria at biopsy, diffuse mesangial proliferation, a high proportion of glomeruli showing sclerosis, crescents or capsular adhesions, the presence of moderate or severe tubulointerstitial changes, and the presence of subepithelial electron-dense deposits and lysis of the glomerular basement membrane by electron microscopy. The percentage of glomeruli displaying crescents, sclerosis and adhesions appeared to be the most reliable prognostic indicator. Nine of the 27 patients (33%) in whom greater than or equal to 30% of glomeruli showed crescents, sclerosis and adhesions developed chronic renal impairment, and only 14% of these patients had normal urine at follow-up. In contrast, only 1 of the 173 patients in whom less than 30% of glomeruli showed such lesions developed chronic renal impairment (p less than 0.001) and 51% of these patients showed complete remission at follow-up (p less than 0.001). These results demonstrate that an accurate prediction of the outcome based on the initial renal biopsy findings is possible early in the course of children with IgA nephropathy.

Renal pathology in rats bearing tumour-secreting growth hormone

The effects of growth hormone (GH) on renal structure and function were investigated in rats aged 10-16 weeks bearing a tumour secreting GH. Body weight gain, food intake, urine volume, and urinary excretion of creatinine and urea nitrogen were significantly greater in tumour-bearing rats than in controls. The tumour-bearing rats presented progressive proteinuria, hyperproteinaemia, and hyperlipidaemia. Creatinine clearance was significantly higher in experimental animals during the early experimental stage, but decreased as the glomerular lesions progressed, associated with a rise in serum creatinine levels. The glomeruli became progressively enlarged with degenerative changes of the visceral epithelial cells and capsular adhesions. In advanced stages proteinaceous material invaded the subcapsular space and the capillary lumen collapsed finally leading to glomerulosclerosis. Except for the presence of proteinaceous material and damaged epithelial cells the glomerular lesions resemble those observed experimentally after reduction of renal mass, and in diabetes mellitus. We speculate that the pathological features described are due to effects of persistently high levels of circulating GH on the glomerular cells.

Image diagnosis for internal derangements of the temporomandibular joint

1. Relationship of the articular disk to the condyle. This study consisted of 175 patients (181 joints) out of 203 patients reviewed. Thirty-eight joints showed anterior disk displacement with reduction, 76 joints showed anterior disk displacement without reduction and 40 joints showed anterior disk displacement with associated perforation of the posterior attachment of the disk. 2. Capsular adhesions of internal derangements of the TMJ. Fifty-five joints (70%) had capsular adhesion in joints showing anterior disk displacement without reduction. Nine joints (21%) had capsular adhesion in joints showing anterior disk displacement with reduction. Arthrotomographically 9 patients were found to have only capsular adhesion without displacement of the disk. 3. Osseous abnormalities of internal derangements of the TMJ. One hundred and one joints were studied. In the patients with anterior disk displacement without reduction, thirty-seven (67%) out of 55 joints had erosive bone changes on the condyle. Nine (17%) out of fifty-three joints with asymptomatic and clinically normal TMJ had erosive bone changes on the condyle. 4. Comparison of double-contrast arthrotomography and MR imaging at 0.2 T. Both methods of evaluation provided highly reliable information regarding the disk. Double-contrast arthrotomography was superior to MR imaging in detecting capsular adhesion and perforation of the posterior attachment. 5. Selection of routine radiographic techniques of the TMJ. The lateral tomograph produced the highest diagnostic accuracy (90%). The diagnostic accuracy of osseous changes of the TMJ is better with rotational panoramic radiography than with lateral oblique transcranial radiography.

Long-term results of surgical treatment of cerebello-pontine angle epidermoids

The long term surgical results in a series of 17 epidermoids of the cerebello-pontine angle are reported. In 11 cases the capsule was removed subtotally and in 6 totally. The absence of mortality among the patients who underwent subtotal removal and the onset of recurrences, if any, only long after the first operation, justify subtotal removal when tight capsular adhesions are present.

Internal derangement of the temporomandibular joint: Radiologic staging with clinical, surgical, and pathologic correlation

The radiologic findings from 60 patients with 86 internally deranged temporomandibular joints (TMJ) upon whom sequential imaging procedures had been performed over a period of two months to ten years were analyzed and correlated with clinical, surgical (72 joints), and pathological observations. Internal derangement of the TMJ disc (meniscus) and osseous structures was found to be an irreversible and progressive disorder with characteristic stages. Internal derangements of the TMJ were divided into early (stage one), intermediate (stages two and three) and late stage (stages four and five) categories based upon radiologic findings obtained with radiography, lateral TMJ tomography and either two compartment arthrography or high field, surface coil MR. After sequential imaging studies, each patient and 72 deranged joints underwent surgical joint exploration and meniscectomy because of progressive joint disease and clinical disability. Surgically removed tissues underwent routine histological evaluation. Surgical and pathologic observations included disc displacement, deformity, hyalination, myxomatous degeneration, perforation of the disc attachments, capsular adhesions, synovitis and mandibular condyle lesions including osteochondritis dissecans (OCD), avascular necrosis (AVN), osseous remodeling and degenerative arthritis. There was excellent correlation between imaging studies and surgical observations. Internal derangement of the TMJ is an irreversible, generally progressive disorder which may be staged and followed with radiography, tomography and either two-compartment arthrography or high field, surface coil MR.