Showing papers in "Clinical Orthopaedics and Related Research in 1991"

The treatment of malignant tumors by repeated inoculations of erysipelas. With a report of ten original cases. 1893.

Abstract: William Bradley Coley (Fig. I) stemmed from old New England stock. After graduating from Yale in 1884. Coley spent two years in Portland, Oregon, teaching Latin and Greek before entering Harvard Medical School. After completing a competitive examination, he became an intern at the New York Hospital

Valgus stability of the elbow. A definition of primary and secondary constraints.

Abstract: The stabilizing structures of the elbow that resist valgus stress were studied with a tracking device in a model simulating active motion and muscle activity. By varying the order of serial release of the medial collateral ligament complex and removal of the radial head, each structure's contribution to valgus stability against the effect of gravity was determined. In the otherwise intact elbow, absence of the radial head does not significantly alter the three-dimensional characteristics of motion in the elbow joint. Isolated medial collateral release, on the other hand, causes increases in abduction rotation of about 6 degrees-8 degrees in magnitude. Releasing both structures results in gross abduction laxity and elbow subluxation. This study defines the medial collateral ligament (MCL) as the primary constraint of the elbow joint to valgus stress and the radial head as a secondary constraint. This definition facilitates the proper management of patients with radial head fractures and MCL disruption. The comminuted radial head fracture uncomplicated by MCL insufficiency should be treated by excision without the need for an implant and without concern of altering the normal kinematics of the elbow.

A sensory role for the cruciate ligaments.

Abstract: Morphologic, physiologic, and clinical evidence for the sensory role of the cruciate ligaments is reviewed. The cruciate ligaments accommodate morphologically different sensory nerve endings (Ruffini endings, Pacinian corpuscles, Golgi tendon organlike endings, and free nerve endings) with different capabilities of providing the central nervous system with information not only about noxious and chemical events but also about characteristics of movements and position-related stretches of these ligaments. A survey of available data reveals that low threshold joint-ligament receptor (i.e., mechanoreceptor) afferents evoke only weak and rare effects in skeletomotor neurons (alpha-motor neurons), while they frequently and powerfully influence fusimotor neurons (gamma-motor neurons). The effects on the gamma-muscle-spindle system in the muscles around the knee are so potent that even stretches of the cruciate ligaments at relatively moderate loads (not noxious) may induce major changes in responses of the muscle spindle afferents. As the activity in the primary muscle spindle afferents modifies the stiffness in the muscles, the cruciate ligament receptors, via the gamma-muscle-spindle system, may participate in the regulation and preprogramming of the muscular stiffness around the knee joint and thereby of the knee joint stiffness. Thus, the sensory system of the cruciate ligaments is able to significantly contribute to the functional stability of the knee joint.

Bone growth factors.

Abstract: Bone volume is determined by the relative rates of bone formation and bone resorption. Recent research in several laboratories suggests that growth factors may act locally to modulate bone formation by stimulating osteoblast proliferation and activity. A number of bone-derived growth factors have been isolated and characterized from bone matrix extracts and from media conditioned by bone cells and bone organs in culture. The growth factors found in bone matrix include insulinlike growth factors I and II, transforming growth factor-beta, acidic and basic fibroblast growth factor, platelet-derived growth factor, and bone morphogenetic proteins. Conditioned medium from bone cells contains several of these growth factors and also hematopoietic factors. These bone matrix-derived growth factors have different biologic activities, including mitogenic, differentiating, chemotactic, and osteolytic activities. Evidence suggests that bone cells produce substantial quantities of growth factors for extracellular storage in bone matrix. Apart from being produced for extracellular storage, it is possible that growth factors secreted by bone cells have acute effects on their neighboring osteoblastic cells, i.e., paracrine action, or on themselves, i.e., autocrine action. The release of matrix-stored growth factors by bone resorption may mean that growth factors act as delayed paracrine agents, e.g., osteoblasts deposit growth factors in bone and later when these growth factors are released from bone via bone resorption, the growth factors stimulate osteoblast precursors to proliferate. The findings that bone is a storehouse for growth factors and that bone cells in culture produce and respond to bone growth factors suggest bone growth factors may act as potential determinants of local bone formation. This review is focused on the structure, regulation, and biologic actions of the known bone growth factors.

A clinical perspective on common forms of acquired heterotopic ossification.

Abstract: The clinical courses of heterotopic ossification (HO) as a consequence of trauma and central nervous system insults have many similarities as well as dissimilarities. Detection is commonly noted at two months. The incidence of clinically significant HO is 10%-20%. Approximately 10% of the HO is massive and causes severe restriction in joint motion or ankylosis. The most common sign and symptom are decreased range of motion and pain. The locations are the proximal limbs and joints. Sites of HO about a joint may vary according to the etiology of the HO. Roentgenographic evolution of HO occurs during a six-month period in the majority of patients. Treatment modalities include diphosphonates, indomethacin, radiation, range of motion exercises, and surgical excision. Surgical timing differs according to etiology: traumatic HO may be resected at six months; spinal cord injury HO is excised at one year; and traumatic brain injury HO is removed at 1.5 years. A small number of patients have progression of HO with medicinal treatment and recurrence after resection. The patients seem recalcitrant to present treatment methods regardless of the HO etiology.

Biomechanical study of ligaments around the elbow joint.

Abstract: The ligamentous contribution to elbow joint stability is a product of morphology and biologic parameters of each of the collateral ligaments. Better understanding of these characteristics is of paramount importance for successful ligament reconstruction in the surgery for joint replacement and traumatic injury. Two experiments were performed. In the first, the arc of elbow flexion where the individual ligament was either taut or slack was measured; in the second, the structural properties of each collateral ligament were determined by using bone-ligament-bone preparations. The anterior medial collateral ligament (AMCL) and radial collateral ligament (RCL) were taut throughout most of the entire arc of flexion. The posterior medial collateral ligament (PMCL) was taut only when the elbow was in a flexed position. Among the collateral ligaments, the AMCL was the strongest and stiffest with an average failure load of 260 N. The palmaris longus tendon, the most frequently used graft for elbow ligament reconstruction, was similar in strength (357 N).

Unicompartmental versus total knee arthroplasty in the same patient. A comparative study.

Abstract: The purpose of this study was to compare unicompartmental knee arthroplasty (UKA) with total knee arthroplasty (TKA) and more specifically to evaluate the role of the patella in patient preference between UKA and TKA. A group of 23 patients were chosen, each with a UKA in one knee and a TKA in the opposite knee. As a subset of the group, 13 patients were compared who had not had patellar resurfacing on their TKA side (Group A) versus ten patients who had patellar resurfacing (Group B). Each patient had a UKA and TKA performed during the same hospitalization. Each patient's resurfacing was performed by the same surgical team. Moreover, inpatient care and physical therapy for each patient's respective UKA and TKA were the same. Patient evaluation consisted of chart review, joint registry data, and telephone interviews that focused on patient preference regarding pain, stability, "feel," and ability to climb stairs. The 23 patients studied had an average follow-up period of 81 months (range, 38-153 months). There were 14 men and ten women with an average age of 67 years. Preoperative diagnosis was osteoarthritis in 22 patients and rheumatoid arthritis in one patient. Range of motion (ROM) improved from a preoperative mean of 106 degrees to 123 degrees postoperatively on the UKA side. Mean ROM for the Group A TKAs improved from 104 degrees to 109 degrees, whereas the Group B TKAs remained unchanged at 113 degrees. For patients surveyed in Group A, 31% stated that their UKA knee was their better knee overall, 15% stated that their TKA knee was their better knee overall, and 54% could find no difference.(ABSTRACT TRUNCATED AT 250 WORDS)

Autologous marrow injection as a substitute for operative grafting of tibial nonunions.

Abstract: Autologous marrow injection was used to stimulate healing in 20 ununited tibial fractures over a five-year period. The technique was employed in conjunction with cast immobilization in ten cases and intramedullary nail fixation in ten cases. Marrow stimulated a callus formation sufficient to unite eight of the ten nonunions immobilized with casts and all ten of the fractures immobilized by intramedullary nails. Bone-marrow injection was as effective as past open autologous grafting but with considerably fewer disadvantages. The technique provides a promptly renewable and reliable source of osteogenic stem cells with numerous advantages compared with standard open-grafting techniques.

The osteogenic potential of culture-expanded rat marrow mesenchymal cells assayed in vivo in calcium phosphate ceramic blocks.

Abstract: When whole marrow is introduced into porous calcium phosphate ceramic, bone forms on the walls of the pores. As an extension of earlier studies, bone marrow cells derived from the femora of inbred rats were introduced into tissue culture, and the adherent cells were cultivated, mitotically expanded, subcultured, harvested, placed in small cubes of porous calcium phosphate ceramic, and grafted into subcutaneous sites of syngeneic rats. Primary marrow-derived, cultured mesenchymal cells introduced into ceramic showed strong osteogenic potential, with bone forming in the pore regions of ceramic as early as two weeks after in vivo implantation; cartilage was observed infrequently in pores that appeared to be avascular. Osteogenesis could be observed after the 18th subculture (over 36 population doublings) when the cells were tested in ceramic at subcutaneous sites, whereas chondrogenesis was observed with only the first and second subcultured cells in the ceramic delivery vehicle. With increasing numbers of subcultures, the initiation of osteogenesis and the apparent rate of bone formation declined, and the course of osteogenesis was delayed. Cultured, marrow-derived mesenchymal cells, even after the 21st subculture (over 40 population doublings), exhibited a positive histochemical reaction for alkaline phosphatase. However, the in vivo osteogenic potential of these cells was not correlated with their alkaline phosphatase activity. The implantation of cell pellets or the injection of cell suspensions of fresh or cultured, adherent marrow cells never produced bone or cartilage in heterotopic sites. These data indicate that porous ceramic provides an excellent delivery vehicle for cells that are capable of osteogenic expression and suggest that the composite graft of marrow-derived mesenchymal cells and porous ceramic may be useful for repair of massive bone defects. It may be possible to culture marrow mesenchymal cells as a source for reparative cells for implantation back into autogeneic sites.

Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale.

Abstract: Ten patients with painful, massive (greater than 5 cm), complete rotator cuff tears involving primarily the supraspinatus were treated with arthroscopic acromioplasty and rotator cuff debridement. All patients except one had normal active motion and strength preoperatively. All patients had roentgenographically normal acromiohumeral distance and an anterior-inferior acromial osteophyte. The goal was to obtain pain relief without loss of motion of strength. This was accomplished in all patients. This study shows that normal shoulder function is possible with a massive unrepaired tear of the rotator cuff. Normal function in the face of an unrepaired cuff tear can occur only if there is a balance of two important force couples, one in the coronal plane and the other in the transverse plane. This balance depends upon the functional integrity of the anterior cuff, the posterior cuff, and the deltoid. In patients whose cuff tears satisfy these anatomic and biomechanical criteria, the achievement of pain relief through arthroscopic debridement and decompression seems to be all that is necessary for normal pain-free function.

Plantar fasciitis. Etiology, treatment, surgical results, and review of the literature.

Abstract: Plantar fasciitis is a common orthopedic syndrome among athletes and nonathletes. The etiology of the pain is multifactorial but usually involves inflammation and degeneration of the plantar fascia origin. The majority of patients will respond to conservative measures. Surgical treatment is reserved for those patients who do not respond. A complete plantar fascia release is performed through a medial longitudinal incision. Prominent heel spurs and degenerated areas in the plantar fascia are resected. Of 27 surgically treated cases followed from one to three years, satisfactory results were obtained in 24 cases. Histologically, localized fibrosis or granulomatous changes or both were noted in several cases.

Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment.

Abstract: An arthroscopic technique and an open technique with malleolar ostectomy for ankle arthrodesis is described and compared. Internal fixation with compression across the tibiotalar joint was utilized for both methods using either 6.5-mm or 7.0-mm cannulated screws. The indications, advantages, results, and complications of these two fusion techniques in 33 patients are reported. Arthroscopic arthrodesis was performed in 17 patients, using open arthrotomy and malleolar ostectomy in 16. The mean time to arthrodesis for patients having the procedure arthroscopically was 8.7 weeks (range, six to 14 weeks), compared to 14.5 weeks in the open arthrotomy group (range, eight to 26 weeks; p less than 0.004). Despite differences in patient selection for each of the two groups, it was concluded that disabling ankle arthritis for certain patients may be more appropriately managed with arthroscopic arthrodesis than by arthrotomy and malleolar ostectomy, utilizing similar methods of internal fixation.

Subvastus (Southern) approach for primary total knee arthroplasty.

Abstract: The subvastus or Southern approach to the knee had been described as early as 1929 but is not found in standard modern orthopedic textbooks. This approach for primary total knee arthroplasty (TKA) preserves the integrity of the extensor mechanism and maintains the vascular supply to the patella. To appreciate the potential benefits of this approach, a complete understanding of the surgical anatomy is essential. The benefits of the subvastus approach make it a valuable technique for primary TKA.

The dominance of cyclic sliding in producing wear in total knee replacements.

Abstract: From a literature survey, it was evident that a wide variety of kinematic conditions occur at the femoral-tibial bearing surfaces, including various degrees of rolling and sliding. A test machine was constructed to reproduce these conditions, applied to spherical-ended metal 'femoral' components acting on a flat polyethylene 'tibial' plateau. The load was cyclic at 2.2 kN for 10 million cycles with distilled water lubricant. For cyclic load only, a shiny depression was formed. With oscillating and sliding superimposed, there was severe surface and subsurface cracking resulting in high wear. When rolling motion was applied, a shiny wear track was formed with minimal cracking and wear. Such surface phenomena were observed in retrieved knee specimens, probably reflecting the kinematics associated with the knee. Low-conformity components inserted with high ligamentous laxity are susceptible to anteroposterior sliding and hence high wear. More-conforming components are less susceptible to wear because they limit sliding as well as reduce contact stresses.

Scapular fractures. Analysis of 113 cases.

Abstract: Scapular fractures have been the subject of study since Desault's treatise of 1805, but few large-scale studies have been completed with long-term follow-up evaluation of displaced scapular neck and spine fractures. This series of 148 fractures in 116 scapulae (113 patients) appears to be the largest ever reported and the only one with a follow-up study of a significant group (24 patients). Significant disability was found in patients with displaced scapular spine and neck fractures: (1) pain at rest in 50%-100%, (2) weakness with exertion in 40%-60%, and (3) pain with exertion in 20%-66%. Based on these findings, the indications for operative management should be expanded to include displaced scapular neck and spine fractures. Using extensile exposure through a posterior Judet incision, rigid internal fixation, and early motion, results in eight cases were excellent. All patients recovered at least 85 degrees of glenohumeral abduction, normal scapulothoracic motion, and none had resting pain, night pain, or pain with abduction. The minimum follow-up study period was 15 months.

Analysis of the failure of 122 polyethylene inserts from uncemented tibial knee components.

Abstract: The extent of wear of retrieved, polyethylene tibial components appears to be related to design. To test this observation, 122 tibial inserts were graded for wear, and new components of several designs were tested for contact stress using Fuji film. Finite element analysis provided insight into subsurface stresses. Significant wear was seen in 61.5% of the tibial inserts examined. The presence of unconsolidated polymer powder was seen in 44% of the tibial inserts and was found to be statistically correlated with severe wear of the articulating surface. Contact stress in several noncongruent designs was found to exceed the yield strength of polyethylene. There was a positive correlation between the intensity of wear and the level of contact stress, with noncongruent designs having greater wear than fully congruent geometries. In the noncongruent designs, the thinner polyethylene components showed greater wear than thicker polyethylene inserts of the same design.

Adjuvant chemotherapy of high-grade osteosarcoma of the extremity. Updated results of the Multi-Institutional Osteosarcoma Study.

Abstract: The Multi-Institutional Osteosarcoma Study (MIOS) was designed to determine whether intensive multiagent adjuvant chemotherapy improves the outcome of patients with nonmetastatic high-grade osteosarcoma of the extremity as compared with concurrent controls. After definitive surgery of the primary tumor, patients were randomly assigned to immediate adjuvant chemotherapy or to observation without adjuvant treatment. Updated results of this trial indicate that the projected six-year event-free survival for the control group is 11% compared to 61% for the chemotherapy group (p less than 0.001). Similar results were observed in patients who declined randomization but who were followed according to the treatment arms of the protocol. When randomized and nonrandomized patients are pooled according to assigned treatment, a survival advantage favoring those patients treated with immediate adjuvant chemotherapy is apparent. An analysis of prognostic factors among patients receiving immediate adjuvant chemotherapy reveals that elevation of the serum lactic dehydrogenase at diagnosis is the factor most predictive of adverse outcome. Location of the primary site in the tibia confers a favorable prognosis. The authors conclude that the natural history of high-grade osteosarcoma of the extremity has not changed over the past two decades. The administration of immediate adjuvant chemotherapy has a significant favorable impact on event-free survival and should be recommended for all such patients.

The antishock pelvic clamp.

Abstract: Unstable posterior pelvic ring disruptions are frequently accompanied by severe venous bleeding and hypotension. Mechanical stabilization has been shown to help reduce such blood loss. A new external fixator called an antishock clamp provides direct reduction and compression of such fracture-diastases about the sacroiliac joint. It is used acutely to rapidly stabilize the posterior pelvic ring in hypotensive patients. The simplicity of design allows the device to be applied in less than ten minutes in the emergency room. Most importantly, it does not interfere with the ability to carry out subsequent laparotomy or other required procedures. Although more clinical experience is needed, the clamp has provided hemodynamic stabilization accompanying fracture reduction. The device is not expected to be of benefit in the cases with significant bleeding of arterial origin.

The use of bone allografts for limb salvage in high-grade extremity osteosarcoma.

Abstract: Limb preservation is increasingly being employed in the local treatment of high-grade extremity osteosarcoma. Bone allografts used to reconstruct the bony defects following tumor resection offer many advantages, including joint reconstruction and incorporation of the graft to the host bone in these relatively young patients. The results of 53 patients 30 years of age or younger were assessed to determine functional outcome. Fresh-frozen allografts were employed as osteoarticular grafts, allograft-arthrodeses, allograft-prosthesis composites, or intercalary grafts. Follow-up intervals averaged 25 months (range, two to 63 months). Life-table analysis showed that the probability of a satisfactory functional result was 73% if local tumor recurrences were excluded. Complications included 16 infections, six fractures, 12 nonunions, and six unstable joints. There were five local recurrences. Eighteen grafts ultimately failed, and in six patients, this resulted in an above-knee amputation. An additional five received a second graft. The functional "end results" of the 38 patients with two or more years of follow-up examinations were 70% satisfactory in those without a local recurrence. There was no statistically significant difference in functional outcome or local or distant relapse in those patients receiving preoperative chemotherapy. The authors conclude that allografts can be used for limb reconstruction in patients with high-grade osteosarcoma who receive aggressive adjuvant chemotherapy. The functional results are comparable to other methods of reconstruction, and once incorporated by the host, offer the advantage of longevity, compared with metallic implants.

Elution of vancomycin, daptomycin, and amikacin from acrylic bone cement.

Abstract: Increasing antibiotic resistance of bacteria that infect prosthetic joints has stimulated interest in the incorporation of more effective antimicrobial agents into polymethylmethacrylate (PMMA). Vancomycin and daptomycin are effective against nearly all staphylococci and streptococci, and amikacin has a broader spectrum against gram-negative bacilli than do other aminoglycosides such as gentamicin. These three antibiotics maintained bioactivity after incorporation into several commonly used preparations of PMMA and eluted readily into the surrounding medium. Preparing PMMA under negative atmospheric pressure, which decreases porosity, caused a 50% reduction in antibiotic release; the addition of 25% dextran, which increases porosity, greatly facilitated elution of these antibiotics. Based on their broad antibacterial effect against gram-positive and gram-negative bacteria, inclusion of vancomycin and amikacin in PMMA merits clinical study. The addition of these antibiotics to PMMA, together with dextran, may be applicable when structural integrity is unimportant but a substantial local antimicrobial effect is desired, such as in the use of antibiotic-containing beads to treat osteomyelitis.

The lateral approach to the valgus knee. Surgical technique and analysis of 53 cases with over two-year follow-up evaluation.

Abstract: Valgus deformity correction poses a major challenge in total knee arthroplasty (TKA). The standard medial approach has many technical limitations and disadvantages that include patellofemoral maltracking and subsequent patellar problems. The lateral approach has been developed and utilized successfully in 79 cases (53 with over two-year follow-up evaluation) since 1980. The biomedical rationale of the approach is sound, and addresses the pathologic anatomy of fixed valgus deformity. Surgical technique is direct, anatomical, more physiologic, and maintains soft-tissue integrity. The "lateral release" is performed as part of the approach. Patellofemoral tracking and alignment stability are optimized and medial blood supply preserved. Clinical experience has shown the approach to be more aesthetic and results objectively superior. Scores have been good/excellent in 94.3% of cases. Knee stability is enhanced with the use of nonconstrained prostheses in this difficult group of patients. The lateral approach is recommended as the "approach of choice" for fixed valgus deformity in TKA.

Comparative aspects of osteosarcoma : dog versus man

Abstract: Canine osteosarcoma bears striking resemblance to osteosarcoma in humans. Similarities include the following: male sex predilection, large patient size, 75% or more affecting the appendicular site, metaphyseal location, generally unknown etiology, less than 10% of patients have documented metastasis at presentation, over 90% of tumors show high-grade histology, 75% of tumors show aneuploidy, the metastatic rate is 80% or more with amputation alone, the lung is the most common site of metastasis, and there is improved survival with adjuvant chemotherapy. The major differences are age of onset, with dogs being affected in middle age; greater frequency in the dog, with over 8000 new cases per year; and time to metastasis being faster in the dog than man. Canine osteosarcoma is a readily available and highly comparable spontaneously occurring cancer that should be useful in a better understanding of the same disease in humans.

Primary total knee arthroplasty in patients with fixed valgus deformity.

Abstract: Ninety-nine knees in 81 patients evaluated from two to ten years and having enough valgus deformity to require specific soft-tissue release were studied. They were also compared to a control group of 40 knees in 31 patients with no angular deformity greater than 5 degrees, who were matched for age and diagnosis. All procedures were performed using a minimally constrained, posterior-cruciate-ligament-sparing prosthesis. Pre- and postoperative axial alignment was measured on weight-bearing long-standing roentgenographs. Analysis included examination for lucent lines in postoperative fluoroscopically positioned roentgenographs and clinical data summarized using the 100-point scoring systems developed by The Knee Society. Knees were classified as having Type I, II, or III valgus deformities: Type I was defined as valgus deformity secondary to bone loss in the lateral compartment and soft-tissue contracture with medial soft tissues intact; Type II was defined as obvious attenuation of the medial capsular ligament complex; and Type III was defined as severe valgus deformity with valgus malpositioning of the proximal tibial joint line after overcorrected proximal tibial osteotomy. Only cases of Type I and Type II were represented in the 99 knees reported. Type I patients were treated with lateral soft-tissue release, and Type II patients were treated with medial capsular ligament tightening (i.e., ligament reconstruction procedures on the medial side). The Knee Society postoperative knee score was 87.6 (+/- 10.6) and mean postoperative functional score was 52.3. Alignment was well corrected and knee scores for the Type I and II groups were almost identical as were the functional scores. The results were grouped as 72% excellent, 18% good, 7% fair, and 2% poor. Notably, the control group was 39 of 40 patients excellent, and only one poor. Ligament stability was satisfactorily established by lateral release in Type I and with the combined medial plication in the Type II patients. The ligament-tightening procedures were on the average 40 minutes longer than those for the Type I or the control groups. The controversial nature of the simultaneous ligament reconstruction method is recognized, but good experience is reported.

Shoulder impingement syndrome. A critical review.

Abstract: Impingement syndrome is an ill-defined term for a variety of disorders of the shoulder that manifest as anterior shoulder pain, especially during overhead activities. These disorders each have a common pathologic course that includes rotator cuff tendinitis (RCT), and, if untreated, may proceed to cuff rupture. RCT has at least two distinct etiologies. Primary impingement of the supraspinatus tendon on the coracoacromial arch is responsible in the majority of nonathletic cases. Overhead movements in sports are prone to developing secondary mechanical impingement because of an instability pattern that is common in this population. Information from this review and clinical practice permits differentiation of the two distinct etiologies of RCT which is important in treatment planning. Much work still needs to be done in defining the microscopic pathology of RCT.

Osteonecrosis of the femoral head. A prospective randomized treatment protocol.

Abstract: Conservative treatment versus core decompression for cases of osteonecrosis (ON) of the femoral head was prospectively reviewed in 36 patients. A preoperative evaluation of the patients' history, physical examination, Harris Hip Score, roentgenograms, computed tomography, bone scan, magnetic resonance imaging, and measurement of the intraosseous pressure was used to grade the level of ON according to a rating system developed by Ficat. Hips were randomized to core decompression or conservative treatment groups. Fifty-five hips in 36 patients were randomized (29 surgical and 26 conservative). When success was gauged by Harris Hip Scores for Stage I hips, treatment was successful for seven of ten (70%) operatively treated hips and one of five (20%) non-operatively treated hips. Among Stage II hips, treatment was successful for five of seven (71%) decompressed hips and none of seven conservatively treated hips. Successful treatment was accomplished in eight of 11 hips (73%) and one of ten hips (10%) in decompression and conservative groups, respectively, for Stage III hips. Stages 0 and IV had groups too small for comparison. Less successful results were seen if roentgenographic criteria of success were used. Survival analysis showed more favorable results with surgical treatment. Core decompression produced better results than conservative treatment in the early stages of ON.

Dislocation of the knee.

Abstract: The results of treatment for vascular and ligamentous injuries in 17 patients who suffered complete dislocation of the knee were reviewed. Eight patients had 23 associated injuries. All nine patients who had injuries of the popliteal artery had arterial reconstruction with saphenous vein bypass grafts, which were successful in eight (89%). Intraoperative arteriography after vascular repair showed a narrowed anastomosis requiring revision in two (22%) of the nine patients and distal thrombi requiring removal in five (55%) patients. Delay in arterial repair was responsible for the one failure. Eleven patients had satisfactory results after early open ligament repair. The results were less favorable in the patients not treated with early ligament repair.

A comparison of tricompartmental and unicompartmental arthroplasty for the treatment of gonarthrosis.

Abstract: An historical prospective study was performed to compare two surgical management alternatives in the treatment of patients with knee arthritis. There were 120 unicompartmental and 81 tricompartmental knee arthroplasties in 98 and 66 patients, respectively. All living patients were available for follow-up observation, and survivorship data on all arthroplasties were obtained. The average follow-up interval was 78 months (range, eight-162 months) in the unicompartmental series and 68 months (range, two- 186 months) in the tricompartmental group. Patients receiving the unicompartmental arthroplasty were treated with nonmetal-backed polyethylene tibial components. Prosthetic survivorship was 92% at ten years in the unicompartmental patient group. There were no statistically significant differences in aseptic loosening between these two patient groups. In appropriately selected patients unicompartmental arthroplasty was associated with better range of motion and ambulatory function than patients being treated with tricompartmental knee replacement.

Knee function after surgical or nonsurgical treatment of acute rupture of the anterior cruciate ligament: a randomized study with a long-term follow-up period.

Abstract: One hundred fifty-six patients with a total rupture of the anterior cruciate ligament (ACL) were reexamined 41 to 80 months after injury. They were randomized to three treatment groups: (1) repair and augmentation of the ACL with an iliotibial strip, (2) repair without augmentation, and (3) nonsurgical ACL treatment. Associated injuries of menisci and other ligaments were treated in the same way for the three groups. Two-thirds of the patients in the nonsurgically treated group complained of instability and 17% had had a subsequent reconstruction of the ACL at the follow-up examination. The group treated with an augmented repair had a less abnormal laxity measured by a laxity-testing device. Sixty-three percent returned to competitive sports, as compared with 27% in the nonsurgical group and 32% in the only repair group. Relative strength of the quadriceps and hamstrings muscles were similar for all groups. The augmented-repair group had better hop tests, reflecting a superior stability, whereas running was not affected by treatment but was correlated with the activity level.

Surgical treatment of brachial plexus birth palsy.

Abstract: Brachial plexus birth palsy remains a challenging condition. In the 1000 infants followed from 1977 to 1988, functional results were much improved over those obtained by observation only, if surgical exploration and repair were performed when no clinical recuperation of biceps function occurred by three months of age. Recovery is slow, and comprehensive follow-up study of reconstructed and conservatively managed children is required to prevent joint contractures. Children who will benefit from palliative procedures such as tendon transfers must also be identified.

Corrosion at the interface of cobalt-alloy heads on titanium-alloy stems.

Abstract: The combination of a cobalt-alloy head on a titanium-alloy femoral hip stem is widely accepted for press-fit and biologic fixation applications. Examination of 30 components retrieved at periods of 0.5 to 66.9 months for histologic examination of tissue ingrowth revealed that 56.6% of the tapered connections between head and stem showed evidence of crevice corrosion leading to concerns of metal ion release and the potential failure of head to stem fixation.