Showing papers in "Journal of Bone and Joint Surgery, American Volume in 1971"

Biochemical and metabolic abnormalities in articular cartilage from osteo-arthritic human hips. II. Correlation of morphology with biochemical and metabolic data.

Abstract: For thirty-two areas of cartilage from nine osteo-arthritic and four "normal" femoral heads a histologic-histochemical grade was assigned as an index of severity of the osteo-arthritic process. The DNA and hexosamine concentrations were determined as indicators of cell density and polysaccharide con

Negative Disc Exploration: AN ANALYSIS OF THE CAUSES OF NERVE-ROOT INVOLVEMENT IN SIXTY-EIGHT PATIENTS

Abstract: In 842 patients, with the clinical diagnosis of root compression due to a disc herniation, laminectomy failed to reveal any lesion of the intervertebral disc in sixty-eight patients. In nine, the source of the root compression was found to be foraminal migration of a sequestrated portion of the intervertebral disc; in twelve, pedicular kinking; in nineteen, articular-process impingement; in eight, segmental spinal stenosis; and in two, a lateral disc protrusion. In eighteen explorations, performed early in the series, no cause could be found for the root compression, and it is suggested that the lack of findings in these cases was due to inadequate exploration of the nerve root. The series analyzed is too small to make any dogmatic statements. However, a plea is entered for a careful appraisal of the level of root involvement preoperatively, using all ancillary methods available—myelography, discography root-sleeve injection, electromyography, diagnostic differential epidural injections—in patients without objective signs of the site of root involvement. Armed with such evidence, it is suggested that a radical exposure of the nerve root should be undertaken in all patients in whom the intervertebral disc fails to reveal pathological changes of sufficient degree to account for the nerve-root compression or tautness demonstrated.

Chemical Basis for the Histological Use of Safranin O in the Study of Articular Cartilage

Abstract: Interpretation of the histological behavior of metachromatic dyes requires information regarding their absorption spectra in solution and in histological sections. This information, previously unavailable for the interaction of safranin O with chondroitin sulphate or keratan sulphate in solution is

Sintered Fiber Metal Composites as a Basis for Attachment of Implants to Bone

Abstract: A fiber titanium composite has been developed and its potential application as a method of skeletal fixation for internal prosthetic devices has been studied.Titanium fibers, 0.19 millimeter in diameter, were cut in short lengths, compressed in dies to predetermined densities, and sintered under vac

Mechanical function of the patella.

Abstract: The patella contributes to the knee extension moment arm through the entire range of knee motion. Its contribution increases with progressive extension. In terms of extension moment, special modifications of transverse repair have no advantage over simple transverse approximation of the patellar lig

The weight-bearing function of the fibula: a strain gauge study

Abstract: The Weight-Bearing Function of the Fibula: A STRAIN GAUGE STUDY KENNETH LAMBERT; The Journal of Bone & Joint Surgery

Flexor-tendon reconstruction in severely damaged hands. A two-stage procedure using a silicone-dacron reinforced gliding prosthesis prior to tendon grafting.

Abstract: Our experience with a Dacron-reinforced silicone tendon prosthesis in the reconstruction of flexor tendons of the hand, first reported in 1965, is brought up to date. Currently the prosthesis is usually used as a passive gliding device which is attached only to the distal phalanx. This implant, inserted as the first stage of a two-stage procedure in conjunction with excision of scar and the reconstruction of a proper pulley system, has been demonstrated to stimulate the formation of a sheath Which provides a durable gliding surface and a nutritional mechanism for a tendon graft which begins to glide early. The indications for this procedure, as well as the preoperative, operative, and postoperative management, are described. The results in five thumbs and sixty-nine fingers, all with less than good conditions for tendon grafting (Boyes' Grades 2, 3, and 5), after follow-ups ranging from six months to eight years, are presented. The complications are also described. The results are compared with those in previously reported comparable cases. The distinctly better results obtained in our series lead us to conclude that the two-stage procedure described is the one of choice for properly selected old injuries where the conditions are less than optimum for tendon grafting.

Pollicization of the index finger. Method and results in aplasia and hypoplasia of the thumb.

Abstract: The experiences with 100 operations of pollicization of the index finger in congenital deformities of the thumb in seventy-three patients are reported on. The operation is indicated in aplasia and in hypoplasia if there is no stable metacarpophalangeal joint and there are adduction contracture and poor mobility due to abnormalities of muscles and tendons. The operative technique was improved by the experiences in twelve years of use. Most important are the bone fixation and the muscle stabilization. In transformation of an index finger into a thumb it is necessary to shorten the ray, to rotate it sufficiently, and to give it the right angle of abduction. The shortening takes place in the metacarpal bone with preservation of its head: the metacarpophalangeal joint becomes now the carpometacarpal joint and the metacarpal head the new trapezium. For preventing a hyperextension deformity it is necessary to rotate the metacarpal head. For good muscle stabilization and good mobility the two interossei of the index finger have to be detached and to be fixed in the shortened position on both sides of the new thumb to the mobilized lateral slips of the dorsal aponeurosis. This new manner of muscle fixation gives a very good thenar eminence not only in respect to appearance but also in function with full or nearly full opposition and abduction. It requires a new skin incision with a dorsoradial skin flap for covering the gap between the wound edges of the former proximal phalanx broadened by the muscle masses. The excellent results show a surprising adaptation of bones and soft tissues due to function and growth—a reason for an early performance of the operation.

Corticosteroid-induced avascular necrosis. A clinical study of seventy-seven patients.

Abstract: A complete review was made of seventy-seven cases of non-traumatic avascular necrosis of bone in patients treated with corticosteroids seen at the Mayo Clinic from 1950 to 1968. The single common finding was treatment with corticosteroids in dosages greater than physiological replacement for long periods either continuously or intermittently. Serum lipids were abnormal in the majority of cases so studied. Roentgenograms showed characteristic segmental avascular necrosis followed by varying degrees of collapse and secondary degenerative changes. Gross and histological study of surgically removed femoral heads confirmed the diagnosis of avascular necrosis. Intravascular fat emboli were noted in a significant number of femoral heads removed from corticosteroid-treated patients with avascular necrosis.

Oxygen tension in zones of the epiphyseal plate, the metaphysis and diaphysis. An in vitro and in vivo study in rats and rabbits.

Abstract: 1. A technique for measuring oxygen tension in different zones of the epiphyseal plate, the metaphysis and the diaphysis in vitro and in vivo is described. 2. In the in vitro preparations (costochondral junctions of twenty-one-day-old rats), there is a distinct oxygen gradient corresponding to the morphological zones, beginning with a low tension of 19.5 millimeters of mercury in the zone of small size cartilage cells and increasing progressively to a high tension of 95.2 millimeters of mercury in metaphyseal bone. 3. In sharp contrast, the in vivo preparations (proximal tibial epiphyses of six-week-old rabbits) exhibited a very low-oxygen tension in the zone of hypertrophic cells and in the metaphysis. 4. A steep gradient in oxygen tension was present between metaphyseal bone (19.8 millimeters of mercury) and diaphyseal bone (108.7 millimeters of mercury) in the in vivo preparations. 5. The significance of these findings is discussed, and the physiological role of oxygen in epiphyseal plate growth is examined.

Medial and Anterior Instability of the Knee: An Anatomical And Clinical Study Using Stress Machines

Abstract: Our clinical stress machine serves as an additional aid in the detection of isolated or combined damage to ligamentous structures about the knee. The machine has greatly assisted in the classification of chronic ligamentous damage. In the questionable gray area of medial instability, machine evaluation has been a great asset in making critical therapeutic decisions.

Surgical Correction of the Resistant Club Foot: ONE-STAGE POSTEROMEDIAL RELEASE WITH INTERNAL FIXATION A PRELIMINARY REPORT

Abstract: A method is described for the early one-stage surgical correction of the resistant, idiopathic, congenital club foot that has failed to respond to non-operative treatment, or has recurred following previous soft-tissue surgery. The method is derived from the procedures previously described by, among others, Codivilla, Brockman, McCauley, and Bost. Of the thirty-one feet which have been followed two years or more postoperatively, one was a failure necessitating further surgery, three were considered to be fair results and the rest were rated good or excellent by rigid clinical and roentgenographic criteria. Based on the preoperative roentgenographic and clinical findings, as well as the operative findings in this small series, it is concluded that (1) a complete correction is best attained with a one-stage posterior and medial soft-tissue release, (2) a lasting corrections is attained only if the correction at operation is complete and temporarily stabilized by internal fixation, and (3) a stress dorsiflexion lateral roentgenogram is the most accurate and reliable method of assessing the correction of the deformity. The technique described has obviated the problems with wound healing, postoperative stiffness, and recurrent deformity which, in the past, have been raised as objections to early soft-tissue surgery. Despite the fact that many of the feet in this series have not been followed until they were skeletally mature, the results to date indicate that a lasting correction can be obtained by a one-stage operation in which the correction is stabilized by transfixing the talonavicular joint with a Kirschner wire and that the best results are obtained when the operation is performed when the child is under two years of age.

Biomechanics of Internal Derangement of the Knee: PATHOMECHANICS AS DETERMINED BY ANALYSIS OF THE INSTANT CENTERS OF MOTION

Abstract: The kinematic technique of instant center analysis of the knee is described. Determination of the instant center or centrode permits identification of the type of motion of the joint surfaces.Twenty-five normal knees were studied and the centrodes were located for the range of motion between full ex

Instability of the Knee: A Long-term Experimental Study In Dogs

Abstract: The anterior cruciate ligament was cut in ten dogs (unilaterally in nine, bilaterally in one). The dogs were killed in two groups, one at seven to nine months and the other at nineteen to twenty-three months. The dogs were clinically and roentgenographically examined at various intervals. At varying times before death they were given bone-seeking fluorochromes and necropsy was performed in all cases. Macroscopic, histological, and microroentgenographic examinations revealed proliferative and degenerative changes in the joints in which the anterior cruciate ligament was cut. These changes became increasingly severe for about a year. The osteophytes, which originated periarticularly, took part in remodeling of the condyles. The osteophytcs increased in size for about a year. There was persistent pain as long as marked instability remained. The knees became less unstable in time, apparently by means of an increase in the thickness of the joint capsule. Most of the clinical signs disappeared with decreasing instability. The conclusion was drawn that early stabilization is indicated in cases of rupture of the anterior cruciate ligament.

Repair and reconstruction of the anterior cruciate ligament in dogs. Factors influencing long-term results.

Abstract: In thirty-eight dogs anterior cruciate repairs were performed and in twenty dogs anterior cruciate reconstructions using the iliotibial band were done. The results were studied for six months to four years postoperatively to determine tensile strength and microscopic anatomy. The results were as fol

Influence of physical activity on ligament insertions in the knees of dogs.

Abstract: 1. At ligament-bone junctions in dogs existing at varying levels of physical activity, strength diminished as activity diminished. 2. At the proximal end of the tibia, subperiosteal resorption weakened the ligament-bone junction of the medical collateral ligament. A similar change was seen in the fibular attachment of the lateral collateral ligament but not in the other ligament attachments about the knee. 3. Microscopically, widespread subperiosteal bone resorption developed in inactive dogs. 4. Simple caging for six weeks or more produed boen resorption. 5. With continued caging, bone resorption at the ligament-bone attachment healed over a period of six months or more as fibrous tissue replaced resorbed bone and then became mineralized. The widespread subperiosteal bone loss consequent to inactivity probably healed in the same way, suggesting on the basis of this histological evidence that inactivity produces bone resorption which is followed by bone accretion.

Fractures of the neck of the femur in children.

Abstract: Experience in a series of seventy-five femoral-neck fractures in children has led to the following conclusions: 1. The transepiphyseal fracture is rare and the results in the two examples reported in this series were poor. 2. Unsdisplaced transcervical and cervicotrochansteric fractures can be adequately treated by simple immobilization in plaster of Paris. 3. Minimally displaced transcervical and cervicotrochanteric fractures, in which considerable contact between the fragments has been maintained, should be reduced by manipulation and immobilized in plaster of Paris. 4. Displaced transcervical and cervicotrochansteric fractures, especially if all bone constact has been lost, remain an unsolved problem. The experience herein reported cannot form the basis of any firm advice about their primary management, except to warn against the use of trifin mails for internal fixation. 5. All pertrochanteric fractures in children can be satisfactorily treated by conservative measures. 6. All fractures of the femoral neck ins children with the exception of pathological fractures can eventually be made to unite by bone, although bone-grafting will sometimes be necessary. 7. The incidence of avascular necrosis ins this series was lower than in most previous reports. Its over-all incidence was 17 per cent in patients seen early. S. Premature epiphyseal fusions occurs in about 17 per cent of patients witin fresh fractures. 9. Coxa vara is the commonest complication, but it is not incompatible with a good result and in the very young may be much modified by remodeling during the process of growth.

Traumatic dislocation of the knee joint. A study of eighteen cases.

Abstract: Eighteen traumatic dislocations of the knee treated at the Los Angeles County-University of Southern California Medical Center in recent years have been analyzed.The findings in this series differ from those in some of the studies reported in the literature. No one individual has had enough experien

Congenital contractural arachnodactyly. A heritable disorder of connective tissue.

Abstract: Twelve kindreds with congenital contractural arachnodactyly, a distinct syndrome of arachnodactyly, dolichostenomelia, contractures, scoliosis, characteristic ear shape, and normal intelligence that is transmitted by autosomal dominant inheritance have been identified in the literature and two additional kindreds described.

Flexor-tendon grafts in the fingers and thumb. A study of factors influencing results in 1000 cases.

Abstract: A study of 1000 consecutive grafts of flexor tendons in the fingers and thumbs has allowed us to develop a consistent technique and a system of evaluation. The first 300 were reported previously. Detailed analysis of the last 700 grafts, 607 in the fingers and ninety-three in the thumb, permits the following conclusions. Scarring from injury or additional scarring from inept previous surgery, or failed primary reparative procedures, compromised the results of secondary tendon grafting. Fingers in which joints had been damaged or in which the interphalangeal joints had become stiffened from neglect did not respond well to tendon grafting, even though the joints were mobilized well before surgery. In fingers with minimum scarring and only one nerve injured, the results were not impaired, but fingers with both nerves damaged had much less motion. The level of tendon injury, whether in the proximal, middle, or distal portion of no-man's land was not a determining factor on the result, nor was the time from injury to operation. Injury of the tendons in more than one digit in itself was not important. The condition of the individual digit determined the outcome for each finger. Other things being equal, patients over forty years of age did not obtain as much motion from tendon grafts as did the patients in younger age groups. The palmaris longus tendon was the best donor tendon, but there was little difference noted when a good superficialis tendon was used. The superficialis of the littie finger and the plantaris tendons are not recommended because of their small size and tendency to rupture. Pulley reconstruction done at the same time as the tendon grafting does not compromise the result. Loss of a few degrees of extension of the interphalangeal joints is not detrimental, but if the total loss of the two joints exceeds 40 degrees in the index or long fingers and 60 degrees in the ring or little fingers, the limitation of extension is significant. When a graft separates at the palmar junction or at its insertion, prompt resuture will salvage at least one-half of the digits. In flexor-tendon grafting in the thumb, the source of the donor tendon, the site of injury, and the presence of considerable scar do not affect the result adversely. The degree of nerve damage had only a minor effect on the result. Grafts extending from the musculotendinous juncture to the terminal phalanx gave better results than the shorter ones. Fingers treated by primary wound closure and insertion of a tendon graft as a secondary procedure had significantly better results than those treated by grafting after an attempted primary tendon repair had failed.

Avascular necrosis of bone after renal transplantation.

Abstract: Two groups of patients underwent renal transplantation and were managed similarly in all respects, except for the dosage of corticosteroids administered post-operatively. For the first group, sixty-eight in number, the dosage was approximately three times greater than that for the second group with 136 patients. Avascular necrosis of bone appeared in sixteen patients in the first group and in two in the second. A greatly increased incidece of avascular necrosis after repeated transplantations was noted.

Fractures of the Lateral Condyle of the Humerus in Children

Abstract: Tirere us no utsanimitv its the literature regarding the mairagemetrt of this itrfrequetst. fracture. Opets reduction and fixation have been recommended by some 1,2,3,4.6,9,I1.13,16 and closed reduction by others 8,lO#{149} All authors on the subject. emphasize that an anatomical reduction is required. We agree with Wilson that “this fracture seems to escape recognitiots and to receive less satisfactory treatment than almost atr ’ other fracture of the elbow” ‘5 The late complications are malunion or IU)I5-tIIS1OIS and these cause deformity, loss of motion, traumatic arthritis, or tardy ulnar neuritis. There is also no agreement on the management of these complications. The injury is an intra-articular transepiphyseal fracture classified as Type IV ill Salter alr(l Harris’ scirema. Four factors cause difficulty in treatment: 1. The pull of the extensors of the wrist and fingers originating on tine condylar fragmeirt tetrds to displace atrd rotate tinat fragment. This force makes the reduction difficult. to ol)tain and maintain. 2. Tire articular surface must be anatomically reconstituted. 3. Segmental injury of the epiphyseal plate increases the possibility for deformitv as a result of disturbance of growth. 4. Svnovial fluid bathing the fracture line may discourage union . Because anatomical reduction is required for proper treatment., the classification of a fracture either as displaced or undisplaced is important. To be classed as undisplaced the fracture must be completely undisplaced in the three standard roetrtgetrographic views-atrteroposterior, lateral, and oblique. Sometimes only the oblique view will reveal displacemeirt. In the truly undisplaced fracture, the line of fracture may he barely detectable atrd may only be seen well after some resorptioti about the fracture line has occurred. In the present study, fifty-two patients were seen for primary treatment, for delayed treatment, or for comrsultation by the staff of St.. Luke’ Hospital, Cleveland, Ohio. Tire age at injury ranged from one and one-half to fourteen years ; the average was 6.9 years. There were thirty-nine boys and thirteen gins. Tire left side was injured in thirty-three ; the right in nineteen. All tire fractures were caused by falls, but more pi’eeise det.ermirratiots of tire mechanism of itrjury usually could not be made. Our fitral follow-up consisted, in forty-one patients, of personal examination, itr seven patients a telephone interview, in one patieist. air answer to a questiontraire, aisci in three 1)atients, reports from otirer orthopaedic surgeons. Roentgenograms at last follow-up were obtained its thirty-three patients, but roent.genograms were trot repeate(l ill those patients who previously had had roentgenograms showing a healed fracture without. deformity surd in wirom there were no symptoms or loss of motiotr. The average length of follow-up was 9.2 years. The lotngest was forty-six years; tire shortest seven months. * Read at the Annual Meeting of The American Orthopaedic Association, hot Springs, Virginia, June 24, 1969. t 10515 Carnegie Avenue, Clevelaind, Ohio 44106. 3461 Warrensville Ceister Road, Cleveland, Ohio 44122. § 3401 Shrine Road, Brunswick, Georgia 31520.

Prevention of thromboembolic disease after elective surgery of the hip.

Abstract: 1. A high incidence (53.6 per cent) of venous thrombosis occurs after elective surgery of the hip. 2. The diagnosis of venous thrombosis by clinical signs and symptoms is far less sensitive than by venography. 3. Low molecular weight dextran has a marked protective effect against the occurrence of thromboembolism as demonstrated in a controlled study of 106 elective hip operations. 4. Low molecular weight dextran has been shown to be safe as well as effective. 5. The prophylactic administration of low molecular weight dextran is recommended for patients undergoing elective surgery of the hip.

The traction spur. An indicator of segmental instability.

Abstract: The traction spur differs from all other spondylophytes in that it is horizontally directed and arises at the site of attachment of the outermost annular fibers about two millimeters away from the discal border of the anterior and lateral surfaces of vertebral bodies. The significance of a traction

Surgical implants. The role of surface porosity in fixation to bone and acrylic.

Abstract: An attempt has been made to measure the bonding capability of bone with implanted materials which have open pores on their surfaces. The results of experimental work in dogs with ceramics, Vitallium with satin surface, and a new type of porous surface finish for Vitallium implants is presented. Firm bonding of bones with the porous-surfaced metal was established by the active infiltration of the porous structure by new bone. Bonding of the metal with methylmethacrylate cement was also greatly enhanced by this porous surface. Some suggestions have been made as to the possible surgical use of such material.

Walking patterns of patients with unilateral hip pain due to osteo-arthritis and avascular necrosis.

Abstract: The simultaneous displacement patterns of parts of the body were analyzed during free-speed anf fast walking of twenty-six men with unilateral hip pain. Despite the variability from one patient to another, certain distinct gait abnormalities emerged as typical of the coxalgic gait.The limp of hip pa

Observations on the effects of tourniquet ischemia.

Abstract: The pH, PO2, and PCO2 in the blood of the extremity operated on under tourniquet control were studied at thirty minute intervals after tourniquet inflation. The degree of acidosis was determined at the various intervals. The post-tourniquet phase was likewise studied at five minute intervals. A discussion of the physiological state of the acidotic extremity as well as the physiological readjustment is presented. A scientific approach to determining a safe waiting period before reapplication of a tourniquet as well as an approach for managing the immediate post-tourniquet phase of an operation is suggested.