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Lung lymphatics cast from the airspace.

Lymphatics are important in the resolution of pulmonary edema, but which lymphatics drain alveolar fluid and how they change during lung injury and edema is uncertain. To study this question 16 rats were exposed to 85% O2 for 7 days. At 0, 3, 7, and 14 days after removal from the hyperoxic chamber, the lungs of the rats were cast by instilling methyl methacrylate into the trachea. The lungs of four similar room-air breathing rats served as controls. Tissue was taken for light microscopy and the casts were examined for lymphatic filling with a scanning electron microscope. Rats exposed to hyperoxia had diffuse damage and extensive edema. On removal from hyperoxia (day 0), 29% of the rat bronchioles had saccular lymphatic casts around them and 6% of bronchioles were surrounded by these lymphatics. Twenty-five percent of bronchioles had conduit lymphatic casts. Fourteen percent of arteries had lymphatic casts around them. All were different from the rats kept in room air (P < 0.0001). Rats exposed to hyperoxia had lymphatics on the pleural surface, near alveoli and alveolar ducts, and around veins. The peribronchial and periarterial saccular lymphatics formed separate groups with communicating conduit lymphatics. The perivenous lymphatics had their own separate conduit lymphatics. Fourteen days after returning to ambient air, the lymphatics were similar to those of control animals. In this model, airway casting allows three-dimensional analysis of the lung lymphatics. It shows that lymphatic compartments expand during hyperoxic lung injury and that peribronchial and perivascular saccular lymphatics connect to conduit lymphatics of the bronchoalveolar bundle.

Animals↗

Early screw fixation versus casting in the treatment of acute Jones fractures.

BACKGROUND: There is considerable variability in the literature concerning the optimal treatment of acute Jones fractures. HYPOTHESIS: Early surgical fixation of acute Jones fractures will result in shorter times to union and return to athletics compared with cast treatment. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Eighteen patients were randomized to cast treatment, and 19 patients were randomized to screw fixation. Success of treatment and the times to union and return to sports were calculated for each patient. RESULTS: Mean follow-up was 25.3 months (range, 15-42 months). Eight of 18 (44%) in the cast group were considered treatment failures: 5 nonunions, 1 delayed union, and 2 refractures. One of 19 patients in the surgery group was considered a treatment failure. For the surgery group, the median times to union and return to sports were 7.5 and 8.0 weeks, respectively. For the cast group, the median times were 14.5 and 15.0 weeks, respectively. The Mann-Whitney test showed a statistically significant difference between the groups in both parameters, with P < 001. CONCLUSION: There is a high incidence (44%) of failure after cast treatment of acute Jones fractures. Early screw fixation results in quicker times to union and return to sports compared with cast treatment.

Adolescent↗

Safety of total contact casting in high-risk patients with neuropathic foot ulcers.

BACKGROUND: Total contact casting (TCC) is effective in offloading the plantar aspect of the foot in patients with diabetes and neuropathic ulcers. These patients are considered at high risk for skin-related complications during TCC because of sensory neuropathy. The purpose of this prospective study was to determine the frequency of complications during treatment of neuropathic ulcers with TCC. METHODS: Thirteen patients with 18 neuropathic ulcers were treated with TCC. The same orthopaedic surgeon applied a consecutive series of 82 total contact casts. The initial cast was changed in 3 to 4 days, while subsequent casts were changed weekly. RESULTS: Fourteen complications occurred during the 82 castings (17%). None of the complications required alteration in the treatment protocol. Thirteen of the 14 complications involved skin irritation and the other complication was from a cast that became too tight. Fifteen of the 18 neuropathic ulcers healed with TCC. CONCLUSIONS: TCC can be used safely in high-risk patients with neuropathic problems, but minor complications should be anticipated. Major complications that interfere with the treatment of the plantar ulcer can be minimized with careful technique, close follow-up, and thorough patient education.

Adult↗

Treatment of Eichenholtz stage I Charcot foot arthropathy with a weightbearing total contact cast.

BACKGROUND: Initial treatment of Eichenholtz stage I Charcot arthropathy of the foot generally is total contact casting and nonweightbearing. This method, however, often is time-consuming and has a poor result. This study was done to determine the success rate of total contact casting in a small group of patients and to establish a benchmark time period for treatment. METHODS: Ten subjects with acute Eichenholtz stage I (stage of development) Charcot foot arthropathy were prospectively treated with weightbearing total contact cast therapy, undergoing biweekly cast changes. One subject did not complete the study. Subjects were monitored with biweekly clinical examination, limb volume measurement, and radiographs. The average age was 58.2 (range 39 to 72) years and weight was 216.9 (range 160 to 275) pounds. RESULTS: All subjects were able to use commercially available depth-inlay shoes and custom accommodative foot orthoses at an average of 9.2 (range 8 to 16) weeks. One subject developed a superficial ulcer that resolved with footwear modification. CONCLUSION: This preliminary study supports the use of total contact cast therapy and weightbearing in the treatment of acute Charcot foot arthropathy. When the total contact cast was changed every 14 days, all subjects were able to use commercially available depth-inlay shoes and custom orthoses.

Adult↗

Parent satisfaction comparing two bandage materials used during serial casting in infants.

Plaster of Paris was compared with semirigid fiberglass casting material during serial casting in 17 infants with clubfoot or rigid metatarsus adductus. Semirigid fiberglass was statistically superior in its durability, convenience, performance, and ease of removal. The average amount of time for home cast removal by the parents was 55 minutes for plaster of Paris and 21 minutes for semirigid fiberglass. Complications such as skin abrasions and cast slip-off were similar for both casting materials. Ninety-four percent of parents strongly preferred semirigid fiberglass rather than plaster of Paris for their child's serial casting.

Casts, Surgical↗

A comparison study of plantar foot pressure in a standardized shoe, total contact cast, and prefabricated pneumatic walking brace.

Total contact casting is the current recommended treatment for Wagner Stage 1 and 2 neuropathic plantar ulcers. The rationale for this treatment includes the equalization of plantar foot pressures and generalized unweighting of the foot through a total contact fit at the calf. Total contact casting requires meticulous technique and multiple cast applications to avoid complications before ulcer healing. An alternative to total contact casting is the use of a prefabricated brace designed to maintain a total contact fit. This study compares plantar foot pressure metrics in a standardized shoe (SS), total contact cast (TCC), and prefabricated pneumatic walking brace (PPWB). Five plantar foot sensors (Interlink Electronics, Santa Barbara, CA) were placed at the first, third, and fifth metatarsal heads, fifth metatarsal base, and midplantar heel of 10 healthy male subjects. Each subject walked at a constant speed over a distance of 280 meters in a SS, PPWB, and TCC. A custom-made portable microprocessor-based system, with demonstrated accuracy and reliability, was used to acquire the data. No significant differences in peak pressure or contact duration were found between the initial and repeat SS trials (P > 0.05). Peak pressures were reduced in the PPWB as compared to the SS for all sensor locations (P < 0.05). Similarly, peak pressures were reduced in the TCC compared to the SS for all sensor locations (P < 0.05) with the exception of the fifth metatarsal base (P = 0.45). Our results are summarized as follows: (1) the methods used in the current study were found to be reliable through a test-retest analysis; (2) the PPWB decreased peak plantar foot pressures to an equal or greater degree than the TCC in all tested locations of the forefoot, midfoot, and hindfoot; (3) compared to a SS, contact durations were increased in both the TCC and PPWB for most sensor locations; and (4) the relationship of peak pressure over time, the pressure-time integral, is lower in the brace compared to the shoe at the majority of sensor locations. The values are not significantly different between the cast and shoe. These findings suggest an unweighting of the plantar foot and equalization of plantar foot pressures with both the PPWB and TCC. Based on these findings, the PPWB may be useful in the treatment of neuropathic plantar ulcerations of the foot.

Braces↗

Cast-bracing for fractures of the femoral shaft. A biomechanical and clinical study.

A study was made of the mechanics of blood-bearing in a series of patients treated with a cast-brace for fracture of the distal femur. Knee hinges incorporating strain-gauges, a simple force-plate on the floor and a standardised weight-bearing test were used to record axial loads through the cast-brace itself and through the fracture during the phases of healing. The cast-brace carried loads of only 10 to 20 per cent of body weight and functioned mainly as an antibuckling hinged tube. Patterns of weight-bearing recovery showed that the fracture itself limited loads to safe levels. A measure of the recovery of strength at the fracture was determined and termed the "fracture load index". Graphs obtained in this way demonstrated four biomechanical phases of bony union which correlated well with the stages of clinical healing. The clinical application of these results have led to improvements in the design of braces and the use of a cylinder cast-brace for fractures of the distal half of the femoral shaft and of a new type of brace with a hinge at the hip attached to the thigh cast for fractures of the proximal shaft. A simple clinical test is described by which it is possible to monitor the healing of fractures in cast-braces.

Adolescent↗

Nonremovable, windowed, fiberglass cast boot in the treatment of diabetic plantar ulcers: efficacy, safety, and compliance.

OBJECTIVE: To compare the efficacy, safety, and compliance of a nonremovable fiberglass cast boot and off-loading shoes in the treatment of diabetic plantar ulcers. RESEARCH DESIGN AND METHODS: Patients (n = 93) with noninfected, nonischemic plantar ulcers were included in this prospective nonrandomized study. Treatment used a nonremovable fiberglass cast boot for longer standing and deeper ulcers (n = 42) and a half shoe or heel-relief shoe for other ulcers (n = 51). We evaluated off-loading therapy, compliance, and complications in both groups. RESULTS: The healing rate was significantly higher with the cast boot than with the off-loading shoe (81 vs. 70%, P = 0.017), with healing times of 68.6 +/- 35.1 vs. 134.2 +/- 133.0 days, respectively, and hazard ratio 1.68 (95% CI 1.04-2.70); complete compliance with treatment was 98 vs. 10% (P = 0.001), respectively. Secondary osteomyelitis developed in 3 patients in the cast boot group and 13 patients in the off-loading shoe group (P = 0.026). CONCLUSIONS: A nonremovable fiberglass cast boot was effective in healing diabetic plantar ulcers and in decreasing the risk of secondary osteomyelitis. The cast boot forced compliance with off-loading, thus promoting healing.

Aged↗

Fracture-suspending effect of the patellar-tendon-bearing cast.

In order to evaluate the fracture-suspending effect of the patellar-tendon-bearing cast, experiments using a load cell under the heel were carried out on four subjects. Measurements were made using a conventional below-knee cast, the PTB cast, and an above-knee cast. There were no differences between the forces transmitted by the same subject wearing the three types of casts in turn and consequently the choice of cast must be based on other factors.

Biomechanical Phenomena↗

Efficacy of gas purging for titanium casting.

Oxygen density in the melting atmosphere, oxygen uptake, hardness and castability of pure titanium castings were examined to evaluate the efficacy of gas purging in reducing contamination from the melting atmosphere and mold, using a newly developed titanium casting machine in which the double purging process is systematized. The adoption of a double purging operation resulted in an extremely low oxygen density in the melting atmosphere, followed by extremely low oxygen uptake in the casting when compared with the conventional titanium casting machine. When the purging operation was used, the surface hardness was markedly reduced, although there was no difference in castability. From these results, it was suggested that the newly developed titanium casting machine with the double purging operation could produce better titanium castings with less contamination due to the mold and gas impurities in melting atmosphere.

Argon↗

Development of casting investment preventing blackening of noble metal alloys part 1. Application of developed investment for Ag-Pd-Cu-Au alloy.

The objective of this study is to develop a casting investment that prevents the blackening of the cast surface of noble metal alloys. The experimental investments were prepared using a gypsum-bonded investment in which the metallic powders such as boron (B), silicon (Si), aluminum (Al) and titanium (Ti) were added as oxidizing agents. An Ag-Pd-Cu-Au alloy was cast into the mold made of the prepared investment. The effect of the addition of each metal powder was evaluated from the color difference between the as-cast surface and the polished surface of the cast specimen. The color of the as-cast surface approached that of the polished surface with increasing B and Al content. A lower mean value in the color difference was obtained at 0.25-1.00 mass% B content. B and Al are useful as an additive in a gypsum-bonded investment to prevent the blackening of an Ag-Pd-Cu-Au alloy. The effects of Si and Ti powder addition could not be found.

Aluminum↗

Mechanical strength and microstructure of laser-welded Ti-6Al-7Nb alloy castings.

Mechanical properties of laser-welded castings of Ti-6Al-7Nb alloy, CP Ti, and Co-Cr alloy were investigated and compared to the unwelded castings using a tensile test. Dumbbell-shaped specimens were cut at the center, and two halves of the specimens were welded with an Nd:YAG laser welding machine at 220 or 260 V of laser voltage. The mechanical strength of 260 V groups was higher than that of 220 V groups for Ti-6Al-7Nb and Co-Cr alloys except for CP Ti. All 260 V laser-welded castings of Ti-6Al-7Nb alloy and CP Ti, which fractured outside the welded joints, exhibited ductile characteristics, while all laser-welded Co-Cr alloy castings, which fractured within the welded joints, showed brittle characteristics. This study proved that the mechanical strength of laser-welded Ti-6Al-7Nb alloy and CP Ti castings was as high as that of unwelded castings, while the mechanical properties of laser-welded alloy joints were influenced by microstructural changes.

Chromium Alloys↗

Experimental binder-free investments reused to cast dental precious alloys.

This study aimed to develop reusable dental investments. SiO2 and MgO were selected as refractory materials to prepare three types of investment (coded as 60S-40M, 80S-20M, 100S) with 40, 20, and 0 wt% of MgO. Each type of investment was reused twice. Thermal expansion and compressive strength were examined and statistically evaluated by ANOVA. To evaluate fit of castings, full crowns were cast by using a commercial Au-Ag-Pd alloy with all investment types. Marginal fit was statistically analyzed by cement thickness. It was found that although MgO strengthened the mold, it had little influence on expansion. The strength of 60S-40M was the highest, and 100S had the greatest advantage with regard to thermal expansion. In the evaluation for clinical applicability, all investments were able to cast successfully, but their castings might be undersized. Among the experimental binder-free investments reused for dental casting in this study, 100S in particular showed to be a good candidate for repeated fabrication of precision fit castings.

Compressive Strength↗

Technique for fabrication of an "instant total-contact cast" for treatment of neuropathic diabetic foot ulcers.

Addressing pressure reduction in the treatment of diabetic foot wounds is a critical component of therapy. The total-contact cast has proven to be the gold standard of treatment because of its ability to reduce pressure and facilitate patient adherence to the off-loading regimen. Removable cast walkers have proven to be as effective as total-contact casts in pressure reduction, but this has not translated into equivalent time to healing. A simple technique to convert the removable cast walker into a device that is not as easily detached from the lower extremity, thereby encouraging the use of this device over a 24-hour period, is presented in this article. The procedure involves wrapping the cast walker with cohesive bandage or plaster of Paris. In the authors' opinion, this technique addresses many of the disadvantages of the total-contact cast, resulting in an adequate compromise in this aspect of care.

Bandages↗

Cast treatment and intramedullary locking nailing for simple and spiral wedge tibial shaft fractures--a cost benefit analysis.

BACKGROUND AND AIMS: The aim of this retrospective study was to compare the relative costs of treating simple and spiral wedge (requiring closed reduction under anaesthesia) tibial shaft fractures in a plaster cast or with intramedullary locking nail. MATERIAL AND METHODS: The material consisted of 26 fractures treated in a plaster cast and 51 fractures treated with an intramedullary locking nail. The costs caused by the direct costs (treatment, hospitalisation, and outpatient appointments) as well as indirect costs (lost productivity) were taken into account. Costs caused by complications were also included in the analysis. RESULTS: Mean direct costs per patient were FIM 22920 and FIM 26952 and mean overall costs per patient were FIM 120486 and FIM 82224 in plaster cast and intramedullary locking nailing groups, respectively (FIM 1 = USD 0.19). The higher mean overall costs of the plaster cast group were attributable to the longer sick leave periods in this group (218 days in plaster cast group and 124 in intramedullary nailing group). CONCLUSION: Plaster cast treatment of simple and spiral wedge tibial shaft fractures requiring closed reduction under anaesthesia is more expensive to society than operative treatment with intramedullary locking nail.

Adult↗

Casting acute fractures. Part 1--Commonly asked questions.

BACKGROUND: Correct splinting of acute fractures offers comfort and is often the definitive treatment for many simple injuries. The use of a cast is a common method of splinting. The best methods for application of casts and their rationale are poorly understood by many doctors and not detailed well in standard texts. OBJECTIVE: This series will attempt to address some common initial casting techniques suitable for general practice. Specific time and cost saving manoeuvres will be given. Common pitfalls will be identified. DISCUSSION: The primary care physician traditionally applies the first cast. This coincides with the time of greatest risk as fractures are potentially unstable, and swelling is often anticipated rather than actually present. The swelling and associated morbidity from a cast can be considerable. Optimising comfort, function and safety in the initial cast is multifactorial. Attention to these factors gives a far better short and long term outcome for the patient. This also reduces medicolegal risk and the cost of unplanned return visits due to unnecessary morbidity.

Casts, Surgical↗

Effects of resistance form on attachment strength of resin-retained castings.

This study evaluated the effects of tooth preparation design on resistance to dislodgment of a resin-bonded fixed partial denture (RBFPD). The variations of tooth preparation tested included axial coverage, retentive grooves, and an occlusal rest. Patterns of the tooth preparation designs were prepared and cast in a base metal alloy. Retainer patterns were waxed to refractory casts of metal dies, cast, finished and then bonded to the dies. The complete assemblies were loaded to failure on an Instron mechanical testing machine, and analysis indicated that retainers with occlusal rests were the most resistant. Grooves provided no statistically significant increase in resistance to failure of the cement. Increased axial coverage did not increase resistance to dislodgment. Successful fixed partial dentures (FPDs) depend on cast retainers to resist displacement of the restoration during function. Introduction of resin-bonded restorations opened the possibility of FPDs with minimal reduction of abutments. Specific questions concerning long term success and tooth preparation designs were prominent concerns. The influence of resistance form on overall stability of a restoration was also of particular interest. Buonocore established the foundation for retention of composite resins to acid-pitted enamel. Rochette used this technology to bond perforated cast metal splints to periodontally compromised teeth. A mechanical interlock was created as composite resin engaged these perforations and sustained the cast splint to acid-etched enamel. Howe adapted this design for replacement of anterior teeth by adding porcelain to a metal ceramic framework and then bonding the framework to abutments without tooth preparations. The advantages of these procedures were their conservative nature, esthetics, and ease of rebonding after dislodgment. Livaditis and Thompson adapted the procedure proposed by Tanaka of corrosion-pitting the bonding surface of a base metal alloy. They increased the surface area to be bonded, eliminated the perforations to improve rigidity of the framework, and described tooth preparation modifications of the abutments. They suggested an occlusal rest, establishment of guide planes through axial reduction, and a proximal extension to the facial surface to resist lingual displacement. Simonson, et al., based their anterior tooth preparation design on the configuration suggested by Livaditis which included a slight chamfer finish line plus reduction of the lingual surface to provide a thicker metal framework. Barrack introduced an inlay type tooth preparation for the occlusal rest plus shallow vertical proximal grooves, and Meiers used grooves as an esthetic alternative to proximal extensions. Clinical studies and surveys have identified specific variables involved with success and failure, while in vitro studies have evaluated framework designs, bonding agents, and methods for pitting the metal surface. This study evaluated resistance of RBFPDs to dislodgment of different tooth preparation designs.

Analysis of Variance↗

Arthrogryposis wrist deformities: results of infantile serial casting.

Arthrogryposis multiplex congenita involving the upper extremity can be associated with significant contractures of major joints. Treatment options to maximize upper extremity motion and function include passive joint stretching, serial casting, or surgical intervention. This study reviewed all patients at Carrie Tingley Hospital with arthrogrypotic wrist flexion contractures treated with passive stretching, serial casting, and custom wrist orthotics to determine the effect on wrist position and function. Seventeen infant patients with distal and classic arthrogryposis used this regimen. Average follow-up was 6 years. The greatest gain in wrist motion occurred after the first casting session for both groups. Patients with distal arthrogryposis had the largest improvement in passive wrist motion, were more functionally independent at final follow-up, and had no recurrence of deformity. Patients with classic arthrogryposis had rigid wrist flexion contractures and a 75% incidence of deformity recurrence after casting. At final follow-up, these patients remained functionally dependent, requiring >50% assistance with activities of daily living, and had less improvement in wrist motion. The authors recommend early casting of infant wrist deformities for both forms of arthrogryposis. If the wrist deformity recurs, repeat serial casting is unlikely to improve wrist extension. Other treatment options may be considered in the older child.

Activities of Daily Living↗