Showing papers in "Journal of Bone and Joint Surgery, American Volume in 1983"

The selection of fusion levels in thoracic idiopathic scoliosis

Abstract: From the material and data reviewed in our study of 405 patients, it appears that postoperative correction of the thoracic spine approximately equals the correction noted on preoperative side-bending roentgenograms. Selective thoracic fusion can be safely performed on a Type-II curve of less than 80 degrees, but care must be taken to use the vertebra that is neutral and stable so that the lower level of the fusion is centered over the sacrum. The lumbar curve spontaneously corrects to balance the thoracic curve when selective thoracic fusion is performed and the lower level of fusion is properly selected. In Type-III, IV, and V thoracic curves the lower level of fusion should be centered over the sacrum to achieve a balanced, stable spine.

The symptomatic anterior cruciate-deficient knee. Part I: the long-term functional disability in athletically active individuals.

Abstract: This study reports on the disability of 103 patients with symptomatic chronic laxity of the an tenor cruciate ligament that was uncomplicated by other associated major ligament deficiency or prior lig ament reconstructive procedures. All of the patients were evaluated at an average of 5.5 years after injury but a subgroup of thirty-nine patients was evaluated at an average of 11.2 years after injury. All had been ac tive in sports, with two-thirds participating in high school or college athletics. The diagnosis of a tear of the anterior cruciate ligament was made by the original treating physician in only seven (6.8 per cent) of the 103 knees. Sixty-four patients (62 per cent) stated that the pain that followed the injury restricted normal ac tivities for longer than three weeks. Eighty-five patients (82 per cent) had returned to some form of sports ac tivity. This gave a false initial impression that the in jury was not eventually disabling for sports, as a sig nificant reinjury occurred in thirty-six patients (35 per cent) within six months and in fifty-three patients (51 per cent) within one year after the original injury. At follow-up five years later, only thirty-six patients (35 per cent) were participating in strenuous sports. A significantumber of patients withlonger follow-up had knee symptoms that affected their routine daily and recreational activities. A subjective moderate to severe over-all disability was reported by thirty-two patients (31 per cent) for walking activities alone, by forty-five patients (44 per cent) for over-all routine activities of daily living, and by seventy-seven patients (74 per cent) for turning or twisting sports ac tivities. Pain occurred in thirty-one patients (30 per cent) during walking activities, in forty-eight patients (47 per cent) during recreational activities, and in seventy-one patients (69 per cent) during strenuous sports activities. Twenty-two patients (21 per cent) complained of giving-way during walking activities; thirty-four patients (33 per cent), during recreational sports; and sixty-six patients (65 per cent), during 4 Supported in part by National Institutes of Health Grants AM2I 172 and AM27517 from the Musculoskeletal Disease Program of the National Institute of Arthritis, Diabetes, Digestive and Kidney Dis eases. t Cincinnati Sports Medicine and Orthopaedic Center, 1 Lytle Place, Cincinnati, Ohio 45202. @ Department ofOrthopaedic Surgery, Hospital ofthe University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. §Department of OrthopaedicSurgery,Universityof Pittsburgh, Pittsburgh, Pennsylvania 15213. strenuous sports. Joint swelling occurred four to five times as frequently in the patients who had had the in jury for the longest time (average, 11.2 years). If the patient had had a meniscectomy, there was a statisti cally significant twofold to fourfold increase in symp toms of pain and swelling related to activity. Giving way was not affected, as this is related to instability of the anterior cruciate ligament. Significant roentgeno graphic changes of arthritis were noted in nineteen (21 per cent) of ninety-one patients starting at an average of 109 months after injury. Seventeen patients (44 per cent) in the subset with the longest follow-up had sig nificant roentgenographic changes. These changes cor related statistically with participation in strenuous sports activities, with running activities, and with giving-way. Important qualifications to this retrospective study are: (1) the patients studied were limited to those with tears of the anterior cruciate ligament who sought treatment for relief of their symptoms, (2) these pa tients continued to be active athletically and thus con tinued to abuse their knees, and (3) none of the patients had had proper initial treatment, rehabilitation, or counseling which might have prevented joint deterio ration. As a whole, the results show the significant functional disability found in the patient with a symp tomatic anterior cruciate-deficient knee, initially for sports activities but later, following reinjury, for meniscal damage, joint arthritis, and the activities of daily living. A dilemma still exists concerning the proper treat ment of a knee with a deficient anterior cruciate ligament, largely because of a lack of knowledge of the extent of the functional disability caused by such an injury'5'8'9―2―@ 21.23.25.27 Our goal was to study a sufficient number of pa tients whose knees demonstrated anterior cruciate laxity alone, without the superimposed variables introduced by previous operative procedures or complicated by other types of ligament instability. The study group also had to contain a sufficient number of patients whose injuries had been sustained at least five years and ten years previously, to allow statistical evaluation of long-term disability. Of importance in this study, as contrasted to many prior studies, is the rigorous grading of symptoms and their severity as related to the specific type of activity during which they occurred. 154 THE JOURNAL OF BONE AND JOINT SURGERY on December 4, 2006 www.ejbjs.org Downloaded from THE SYMPTOMATIC ANTERIOR CRUCIATE-DEFICIENT KNEE 155 years earlier (range, three months to 33.3 years). Twelve patients had been injured one year earlier and thirty-three, two years earlier. For a portion of the analysis, the group was divided into sixty-four patients who had been injured less than five years earlier and thirty-nine patients who had been injured at or more than five years earlier. The symptoms of pain, swelling, and giving-way were ranked as slight, moderate, or severe, as follows: slight —? occasional recurrent minor discomfort, not inter fering with activity; moderate —? symptoms usually brought on by an activity, interfering with activity, and relieved by stopping activity or rest; and severe —? symp toms occurring with activity, persisting and lasting over night or days, significantly interfering with activity (usu ally the patient must stop activity). Of the 103 patients in this study, fifty-one had had a meniscectomy, including six patients who had two menis cectomies. A total ofsixty-five menisci had been removed, of which forty-seven were medial, thirteen were lateral, and five were unknown. Fourteen patients had had both menisci removed. Fourteen meniscectomies had been per formed within three weeks after the initial injury and thirty-seven, within one year after injury. The remainder of the procedures were distributed throughout the remain ing years. Roentgenograms of ninety-one of the 103 knees were graded for degenerative arthritic changes, as follows: mm imum —? squaring of femoral and tibial margins, sub chondral sclerosis, no joint narrowing, and no significant osteophyte formation; moderate —? narrow joint-cartilage space, significant subchondral sclerosis, and osteophyte formation; or severe —? the aforementioned criteria plus obliteration of the joint-cartilage space.

The synovial-like membrane at the bone-cement interface in loose total hip replacements and its proposed role in bone lysis.

Abstract: The membrane present at the bone-cement interface was retrieved from twenty patients with a loose, non-septic failed total hip replacement at a site clearly remote from the pseudocapsule that reformed postoperatively. The orientation of the membrane was carefully marked to identify the surface in contact with cement. The membrane was studied histologically, histochemically, by cell culture, by organ culture, and by assessment of its ability to synthesize prostaglandin E2 and collagenase. This membrane, rather than being a nondescript so-called fibrous membrane, has the histological and histochemical characteristics of a synovial-like lining. The synovial-like cells are adjacent to the cement layer. Deep to them macrophages predominate. Inflammatory cells are absent. Cell cultures of this membrane contain stellate cells similar to those found in cell cultures of normal and rheumatoid synovial tissue. This membrane has the capacity to produce large amounts of prostaglandin E2 and collagenase. Clinical Relevance: This transformation of tissue at the bone-cement interface in patients with a non-septic, loose total hip component to a synovial-like tissue with the capacity to generate prostaglandin E2 and collagenase may explain the progressive lysis of bone that is seen in some patients with loose cemented total joint implants. Loosening of the component may be a stimulus to the synthetic activity of this tissue, which leads to further resorption of bone. Understanding and the possibility of pharmacological control of this membrane may contribute to improved duration of total joint implants.

Cuff-tear arthropathy.

Abstract: In this report we describe the clinical and pathological findings of cuff-tear arthropathy in twenty-six patients and discuss the differential diagnosis and a hypothesis on the pathomechanics that lead to its development. This lesion is thought to be peculiar to the glenohumeral joint because of the unique anatomy of the rotator cuff. Following a massive tear of the rotator cuff there is inactivity and disuse of the shoulder, leaking of the synovial fluid, and instability of the humeral head. These events in turn result in both nutritional and mechanical factors that cause atrophy of the glenohumeral articular cartilage and osteoporosis of the subchondral bone of the humeral head. A massive tear also allows the humeral head to be displaced upward, causing subacromial impingement that in time erodes the anterior portion of the acromion and the acromioclavicular joint. Eventually the soft, atrophic head collapses, producing the complete syndrome of cuff-tear arthropathy. The incongruous head may eventually erode the glenoid so deeply that the coracoid becomes eroded as well. Although treatment of cuff-tear arthropathy is extremely difficult, the preferred method appears to be a resurfacing total shoulder replacement with rotator-cuff reconstruction and special rehabilitation. We think that it is important to recognize cuff-tear arthropathy as a distinct pathological entity, as such recognition enhances our understanding of the more common impingement lesions. Cuff-tear arthropathy is especially difficult to treat, and although many tears of the rotator cuff do not enlarge sufficiently to allow this condition to develop, it is a factor to consider when deciding whether or not a documented tear of the rotator cuff should be surgically repaired.

Dislocation arthropathy of the shoulder.

Abstract: Seventy-four shoulders in seventy patients with a history of single or multiple dislocations of the shoulder demonstrated radiographic evidence of glenohumeral arthropathy. In every patient radiographs of the contralateral shoulder failed to reveal any abnormality (except, of course, in patients with bilateral dislocation). There were sixty-two anterior and eleven posterior dislocations, and one multidirectional dislocation. Shoulders with a posterior dislocation had a much higher incidence of moderate and severe arthrosis than those that had an anterior dislocation. This seemed to be related to delay in diagnosis. The number of recurrent dislocations or the presence of defects of either the glenoid rim or the humeral head, or both, was not related to the severity of the arthrosis. Operations in which internal fixation devices intruded on joint cartilage frequently resulted in moderate to severe arthrosis. Ten of the fifteen shoulders with severe arthrosis and six of the fourteen with moderate arthrosis had had no operation for the dislocation. Six of these sixteen shoulders had had a posterior dislocation for which reduction had been delayed.

Risk factors in low-back pain: an epidemiological survey.

Abstract: A survey was done on 1221 men between the ages of eighteen and fifty-five years who had been seen in a family-practice facility between 1975 and 1978 Each patient completed a questionnaire concerning any history of low-back pain, associated symptoms in the lower limbs, resultant disability,

Curve progression in idiopathic scoliosis.

Abstract: One hundred and thirty-three curves in 102 patients who were followed for an average of 40.5 years were evaluated to quantitate curve progression after skeletal maturity and for prognostic factors leading to curve progression. Sixty-eight per cent of the curves progressed after skeletal maturity. In general, curves that were less than 30 degrees at skeletal maturity tended not to progress regardless of curve pattern. In thoracic curves the Cobb angle, apical vertebral rotation, and the Mehta angle were important prognostic factors. In lumbar curves the degree of apical vertebral rotation, the Cobb angle, the direction of the curve, and the relationship of the fifth lumbar vertebra to the intercrest line were of prognostic value. Translatory shifts played an important role in curve progression. Curves that measured between 50 and 75 degrees at skeletal maturity, particularly thoracic curves, progressed the most.

Two-Stage Reimplantation for the Salvage of Infected Total Knee Arthroplasty

Abstract: The results of eleven two-stage reimplantations to salvage eleven infected total knee arthroplasties in ten women (seven with osteoarthritis and three with rheumatoid arthritis) were evaluated after an average follow-up of thirty-four months. The staged procedures included removal of all of the components of the prosthesis and all cement, then six weeks of parenteral antibiotic therapy (monitored by maintaining serum bactericidal levels at a peak dilution of 1:8), and finally reimplantation with a total condylar-type prosthesis. All antibiotics were discontinued after reimplantation. At follow-up, no patient had had a recurrence of the original infection, but one had a hematogenous infection with a different organism secondary to an infected bunion. The results after reimplantation were rated excellent in five knees, good in four, and fair in two. Weakness of the extensor mechanism with an extension lag was the most frequent complication. We do not believe that antibiotic therapy alone is adequate for the management of an infection around a prosthesis. The method described appears to be effective but it is costly and time-consuming. The surgical procedures and medical management are technically difficult, often special equipment and a custom-made prosthesis are required, and there are no shortcuts.

Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure.

Abstract: For the past five years we have attempted to correct knee instability due to rupture of the posterior cruciate ligament with a procedure that employs a free graft of one-third of the patellar tendon with its tibial and patellar attachments. This procedure was done for chronic instability in thirty-three patients and was combined with primary repair of an acute mid-substance tear of the posterior cruciate ligament in fifteen patients. Moderate to severe articular injury of the medial femoral condyle was found at operation in 48 per cent of the patients with chronic injury. Seventy-one per cent of the patients for whom the interval between injury and ligament reconstruction was two to four years, and 90 per cent of those for whom the interval was more than four years, showed articular injury of the medial femoral condyle. Only 31 per cent of the patients, however, had preoperative radiographic findings that indicated femoral articular damage. Twenty-three of the twenty-five patients with a minimum follow-up of two years returned for evaluation. All of the ten patients who had had a repair and reconstruction of an acute ligament injury (whose average follow-up was forty-one months) had a static and functional result that was graded as good or excellent. Of the thirteen patients for whom surgery was done for chronic instability (whose average follow-up was thirty-one months), the over-all static and functional result was graded as good or excellent in eleven. These results indicate that the use of one-third of the patellar tendon for reconstruction in patients with acute mid-substance tears as well as in patients with symptomatic chronic instability of the posterior cruciate ligament is an effective procedure for achieving static and functional stability of the knee.

The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification.

Abstract: We studied 100 consecutive patients with potentially unstable fractures and fracture-dislocations by multiplane computed tomography. The mechanism of failure of the middle osteoligamentous complex of the spine (posterior longitudinal ligament, posterior part of the vertebral body, and posterior annulus fibrosus) was determined by three-dimensional analysis. Three modes of middle-column failure were used to classify the injuries: axial compression (seventy-three patients), axial distraction (fifteen patients), and translation within the transverse plane (twelve patients). Fifty of eighty-six patients who were evaluated in the acute phase of injury underwent operative stabilization, and the mechanism of middle-column disruption determined the type of instrumentation that was used. Compression and distraction injuries of the middle complex could be appropriately treated by Harrington distraction and compression instrumentation, respectively. However, in translational injuries (torn posterior longitudinal ligament) routine Harrington instrumentation was contraindicated due to the risk of overdistraction. Translational injuries were associated with the greatest degree of instability and often had complete ligament discontinuity at the level of the affected vertebrae. Patients with a translational injury had the most severe neural deficits (six of eleven patients studied acutely having a complete spinal cord lesion). Translational injuries of the middle column were treated by segmental spinal instrumentation to provide strong fixation with minimum risk of neural sequelae from passing sublaminar wires. Moreover, postoperative use of a cast over insensate skin was not required. Computed tomography was more sensitive than any other modality in the diagnosis of disruption of the posterior elements in unstable burst fractures, and computer-reconstructed sagittal images were accurate in evaluating the nature of facet-joint failure in distraction injuries. Computed tomography with metrizamide proved superior to either conventional tomography or myelography alone in localizing the site of neural canal compromise in acute thoracolumbar injuries. The mode of failure of the middle osteoligamentous complex as visualized by computed tomography determined the pattern of spinal injury, the severity of the neural deficit, the degree of instability, and the type of instrumentation required.

The total condylar knee prosthesis in gonarthrosis. A five to nine-year follow-up of the first one hundred consecutive replacements.

Abstract: We studied the first 100 consecutive patients (125 knees) to undergo knee arthroplasty with the original total condylar-I prosthesis for either osteoarthritis or osteonecrosis on the Knee Service at The Hospital for Special Surgery. They were followed for an average of 6.6 years (range, five to nine years), which is the longest follow-up of a total knee prosthesis that is still widely used in its original and unmodified form. At five to nine years of follow-up, eleven patients (fourteen knees) were dead and ten patients (eleven knees) could not be traced, leaving 100 knees (seventy-nine patients) for clinical evaluation. This included one knee from which the prosthesis was removed for sepsis at six months, four that were revised for pain, and two that were revised because of subluxation. Two patients had a loose tibial component. Sixty-four knees were rated as excellent and twenty-seven were rated as good. There were two fair and seven poor results. Detailed radiographic evaluation of the 100 knees showed that only minimum changes in the varus or valgus alignment or the fixation of the prosthetic components had occurred with time. At follow-up, 41 per cent of the tibial components showed some evidence of radiolucency, although with the exception of the two loose components just mentioned there were no complete or circumferential radiolucent lines. Most radiolucencies were present by the end of the first postoperative year, and in 81 per cent of the knees there was no further change. Although a special attempt was made to determine any evidence of wear of the polyethylene tibial component, we were unable to demonstrate unequivocal wear in any knee. Our experience had led us to conclude that the long-term success of current total knee designs will probably not be significantly affected by polyethylene wear or loss of component fixation. The majority of failures in our series were attributed to errors in surgical technique.

Development of the menisci of the human knee joint. Morphological changes and their potential role in childhood meniscal injury.

Abstract: Development of the menisci of the human knee joint. Morphological changes and their potential role in childhood meniscal injury. C Clark;J Ogden; The Journal of Bone & Joint Surgery

Total hip arthroplasties in patients less than forty-five years old.

Abstract: We studied the cases of eighty-one patients (108 total hip arthroplasties), ranging in age from fourteen to forty-five years, at an average of 4.5 years after the index operation and evaluated them with regard to six major factors: age, disease, Charnley category, prior operations, length of time since arthroplasty, and quality of the arthroplasty with regard to cementing technique and component position. After two to five years 78 per cent were satisfactory, but after five years or more only 72 per cent were satisfactory. Patients who were less than thirty years old had poorer results. Good technique yielded 93 per cent satisfactory clinical results. The patients in this study with the worst prognosis for success following total hip arthroplasty were less than thirty years old, had osteonecrosis or osteoarthritis as the primary disease, and had a less than optimum reconstruction. Patients who were alcohol-abusers or who had had a prior hip infection or a prior acetabular cup or femoral hemiarthroplasty also had a poor prognosis. Patients who had the arthroplasty for collagen disease or were thirty years old or older, or both, and had a good technical reconstruction had the best prognosis.

Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment.

Abstract: During the years 1978 and 1979, the results in 257 patients with a primary anterior dislocation of the shoulder were prospectively studied. The patients were less than forty years old and had been treated at twenty-seven Swedish hospitals. Thirty-two patients had a fracture of the greater tuberosity, but none of them reported having any further dislocations within two years after treatment, while 32 per cent of the patients without this fracture had a redislocation during the same period. The incidence of fractures of the greater tuberosity varied with the age of the patient; the highest rates were in the age groups of twelve to thirteen years and thirty-four to forty years (43 and 30 per cent, respectively), while in the age group of twenty to twenty-two years this injury was found in only 3 per cent of the patients. Chip fractures of the glenoid rim were found in 8 per cent of the patients, most of whom were in the older age groups. Impression fractures in the posterior part of the humeral head were demonstrated in 55 per cent of the patients and were not associated with a significantly higher rate of recurrence of dislocation. One hundred and twelve patients used an immobilization device for three to four weeks, while 104 patients began to use the shoulder as early and as freely as possible. At the two-year follow-up the groups showed an equal rate of recurrence of dislocation. In the age group of twenty-two years or younger nearly 50 per cent of the patients had one or more recurrences, regardless of treatment. In the two older age groups (twenty-three to twenty-nine and thirty to forty years old), the incidence of recurrence was 25 per cent or less.

Non-operative treatment of complete tears of the medial collateral ligament of the knee.

Abstract: A prospective study was designed to compare the results of operative and non-operative treatment of complete (Grade-Ill) isolated tears of the medial collateral ligament of the knee. For eighteen consecutive months, all patients suspected of having this injury were examined under anesthesia and arthroscopically before primary surgical repair was performed. At the time of surgery, the preoperative diagnosis was confirmed in all knees. Surgery was followed by a six-week period of immobilization of the knee in a plaster cast and a well defined, supervised rehabihitation program. These patients comprised Group I. For the ensuing eighteen months, all patients with this injury of the medial collateral ligament were also exammed under anesthesia and by arthroscopy but were treated by immobilization of the knee in a plaster cast for two weeks, the use of a cast-brace for four weeks, and the same rehabilitation program as was used in Group I. These patients comprised Group II. Sixteen patients in Group I were followed for an average of 3.1 years and twenty patients in Group II, for an average of 2.4 years. In both groups, examination under anesthesia and arthroscopic evaluation of the intraarticular structures demonstrated that there was no structural damage to the anterior cruciate ligament, menisci, or articular surfaces. Fifteen of the sixteen patients in Group I and seventeen of the twenty patients in Group II had a good or excellent result. The results seem to indicate that primary surgical repair of a complete (Grade-HI) isolated tear of the medial collateral ligament is not necessarily indicated. Rehabilitation was expedited in the patients who were treated with cast-bracing alone, since these patients regained their strength, as measured by the Cybex-il machine, in significantly (p < 0.001) less time (Group I, 14.9 ± 1.5 weeks and Group II, 11.3 ± 1.8 weeks) . The key to success in the treatment of this injury is to establish that there is an isolated lesion with no associated damage to other vital structures, particularly the anterior cruciate ligament and the menisci. It has been well documented in the orthopaedic hiterature, in both laboratory and clinical studies, that predictably good or excellent results can be obtained by primary : Department of Orthopaedics, College of Medicine, University of Florida, Box J-246, JHM Health Center, Gainesville, Florida 32610. repair when the medial collateral ligament is completely torn. In 1938, Palmer described the results after primary repair. Over the past thirty years, O’Donoghue has advocated surgical intervention for all complete tears of the medial collateral ligament13’7. Godshahl and Hansen, in 1974, recommended primary surgical repair whenever the valgus stress test on an injured knee produces a relative increase in the width of the medial joint space of four millimeters or more. Many other investigators also reported consistently good to excellent results following primary repair of a completely torn medial collateral higament’’4’7”#{176}19. On the other hand there have been other, less well known reports that described non-operative approaches in the treatment of this lesion. In 1946, Richman and Barnes used a closed method of treatment for significant damage to the knee ligaments of parachutists. Of the eighty-five patients whose cases they reviewed, the vast majority (95 per cent) had an excellent result after six to ten weeks of immobilization in a plaster cast with the knee in 30 degrees of flexion. In 1974, Ellsasser et al. listed strict criteria for the non-operative management of injuries of the collateral ligaments, which when carefully followed gave a success rate of 98 per cent. More recently, Fetto and Marshall described a rationale for treating these injuries. In a retrospective study of twenty-one patients with an isolated tear of the medial collateral ligament, they found that ‘ ‘isolated Grade III [complete] MCL injuries did equally well under non-operative as operative treatment”. O’Connor described certain indications for non-operative treatment of complete tears l , including the presence of an infected turf burn or a severe upper-respiratory infection that precluded surgery. Under these circumstances, he recommended that patients be treated with immobilization of the knee in a plaster cast for at least four weeks. Previous laboratory studies have provided some support for this non-operative approach. Jack produced cornplete tears of the medial collateral ligament in cats by forceful abduction of the knee over the edge of an operating table. The presence of a complete tear was confirmed surgically, and in some animals displacement of the torn ends was allowed to remain. Even though no immobihization was used, healing occurred provided the ends of the torn ligament were not widely separated. Clayton and Weir compared the results in repaired and unrepaired tears of the medial collateral ligament in dogs. Although the reLIG. MEDIAL CAPSULAR

Quantitative criteria for prediction of the results after displaced fracture of the ankle.

Abstract: In a series of 146 displaced ankle fractures, the effects of age, sex, side of injury, mechanism of injury, severity as determined by the Lauge-Hansen classification, type of injury (open or closed), open or closed treatment, and internal fixation of one or both malleoli were analyzed using subjective, objective, and radiographic parameters. Statistically significant prognostic features were identified and a prognostic scale was developed using multiple linear-regression analysis. The significant parameters were age, adequacy of the post-reduction positions of the medial and lateral malleoli, and completeness of the restoration of the deltoid ligament and distal tibiofibular syndesmosis. Open reduction proved superior to closed reduction, and in bimalleolar fractures open reduction of both malleoli was better than fixing only the medial side. Using the data on the first 109 fractures, a multiple linear-regression equation was formulated and used to predict the outcomes of the last thirty-seven fractures in the study. The accuracy of the predictions in them was 81 per cent.

Pyogenic and fungal vertebral osteomyelitis with paralysis.

Abstract: A retrospective review of the cases of sixty-one patients with vertebral osteomyelitis revealed that the associated diseases of diabetes mellitus and rheumatoid arthritis as well as increased age and a more cephalad level of infection predisposed to paralysis. For patients with paralysis and a long-term follow-up, the prognosis for isolated nerve-root deficits is good with or without surgery. For patients with spinal cord compression, the results generally are better with anterior decompression and stabilization than with laminectomy. Early treatment should be directed at prevention of intrinsic spinal-cord damage, which is irreversible.

Flexor tendon healing and restoration of the gliding surface. An ultrastructural study in dogs.

Abstract: Healing canine flexor tendons were treated with either total immobilization and were studied by light, scanning, and transmission electron microscopy at ten, twenty-one , and forty-two days. The immobilized tendons healed by ingrowth of connective tissue from the digital sheath and cellular proliferation of the endotenon. The ingrowth of reparative tissue from the digital sheath overwhelmed the epitenon response. At the ultrastructural level, collagen resorption was prominent whereas protein synthesis was limited. This was observed at all study-intervals. In contrast, the mobilized tendons healed by proliferation and migration of cells from the epitenon. Ingrowth of reparative tissue from the tendon sheath was notably lacking in this group. The epitenon cells exhibited greater cellular activity and collagen production at each interval compared with cells of the immobilized repairs.

Acute posterolateral rotatory instability of the knee.

Abstract: We reviewed the clinical records and operative notes of seventeen consecutive patients who were treated by surgical repair for acute posterolateral rotatory instability in order to determine the diagnostic features of the instability and the effectiveness of our surgical repair in thirteen patients who returned for objective and subjective evaluation after a mean follow-up of 53.3 months. Sixteen of the seventeen knees had a positive external-rotation recurvatum test; fifteen, a positive adduction-stress test at 30 degrees of knee flexion; and twelve, a positive posterolateral-drawer test. Associated rotatory instabilities were found in ten of the seventeen knees, with anterolateral rotatory instability being the most frequent. Two patients had associated peroneal-nerve palsy. One or more components of the arcuate ligament complex were injured in all seventeen knees. None of the thirteen patients who were followed required subsequent reconstruction for any chronic instability. Of these thirteen, the results in 85 per cent were rated good subjectively and in 77 per cent, good objectively. Eighty-five per cent of these patients had returned to athletic activity at their preinjury level; the remaining 15 per cent did not participate in sports activities. A positive posterolateral-drawer test or external rotation recurvatum test, or both, was diagnostic of posterolateral rotatory instability. The adduction stress test at 30 degrees of knee flexion was usually positive, but was not diagnostic. Accurate diagnosis and treatment of posterolateral rotatory instability in the acute stage can result in subjectively and objectively acceptable knee function.

Suture of new and old peripheral meniscus tears.

Abstract: A prospective study of repaired vertical peripheral tears of the meniscus in fifty patients (nine women and forty-one men) was carried out from January 1977 to June 1980. All tears were confirmed preoperatively by arthroscopy. Forty-three medial and seven lateral menisci were repaired. Fifteen tears were treated within two weeks and thirty-five were operated on as long as seven years after injury. Only eight patients had a meniscal tear that was not accompanied by injuries of either the anterior cruciate ligament or the collateral ligaments, or both. At a mean follow-up of eighteen months (range, six to thirty-nine months), forty-two patients (84 per cent) had clinically apparent healing of the sutured meniscal tear. Repeat arthroscopy was done in twenty-seven (64 per cent) of these patients, four to twenty-nine months (mean, twelve months) after the operation. The arthroscopy proved that all of these repaired tears had healed. Eight patients had a second tear after the initial repair: four were reruptures at the sutured area and four were new ruptures in another area of the meniscus and were associated with fresh trauma. All of these patients subsequently had an arthroscopic meniscectomy.

Sensibility testing in peripheral-nerve compression syndromes. An experimental study in humans.

Abstract: Sensibility testing in peripheral-nerve compression syndromes was investigated in an experimental study in humans. Twelve volunteer subjects had controlled external compression of the median nerve at the carpal tunnel at a level of forty, fifty, sixty, and seventy millimeters of mercury. The subjects were then monitored for thirty to 240 minutes with four sensory tests: two-point discrimination, moving two-point discrimination, Semmes-Weinstein pressure monofilaments, and vibration. Sensory and motor conduction, subjective sensations, and motor strength were also continuously tested. The threshold tests (vibration and Semmes-Weinstein monofilaments testing) consistently reflected gradual decreases in nerve function in both subjective sensation and electrical testing, while the innervation density tests (two-point discrimination and moving two-point discrimination) remained normal until nearly all sensory conduction had ceased. Decreased muscle strength occurred late, and not until changes had already occurred in each of the sensory tests. Threshold tests of sensibility correlated accurately with symptoms of nerve compression and electrodiagnostic studies, and are being evaluated for clinical use in a variety of peripheral-nerve compression syndromes.

The effects of indirect blunt trauma on adult canine articular cartilage.

Abstract: In order to determine the effect of subfracture loads on articular cartilage, we impacted twelve adult canine patellofemoral joints utilizing a drop-tower with two different force-levels The joints were examined with light and electron microscopy at two, four, and six weeks after impaction In ten additional animals a single knee was impacted and they were analyzed biochemically at similar time-periods, using the contralateral joint as a control In all impacted specimens changes were observed in the zone of calcified cartilage, represented by an increase in cellular clones, vascular invasion, and proteoglycan content of the matrix Ultrastructural evaluation of the superficial and deep radial zones of the articular cartilage revealed loss of the cellular processes and territorial matrices of chondrocytes in both layers Ruthenium-red staining of impacted samples revealed a 40 per cent decrease in proteoglycan associated with collagen fibers in the extraterritorial matrix An increase in collagen-fiber width was observed in the four and six-week groups The earliest changes in articular cartilage included activation of the zone of calcified cartilage as well as ultrastructural alterations in the superficial and radial zones Biochemical analysis revealed an increase in water content and hexuronic acid at two weeks These changes occurred at a subfracture level in the absence of surface disruption CLINICAL RELEVANCE: These animal experiments indicate that adult articular cartilage may show significant alterations in its histological, biochemical, and ultrastructural characteristics without disruption of the articular surface This model of articular cartilage "contusion" may represent a corollary to the joint damage that is observed following direct blunt trauma transmitted across articular surfaces without radiographic evidence of fracture The possibility that this form of injury may be the precursor of chondromalacic changes in patellar or femoral cartilage merits further study

Non-operative treatment of the torn anterior cruciate ligament.

Abstract: The purpose of this study was to assess and describe the status of twenty-four patients with a diagnosed tear of the anterior cruciate ligament who participated in a non-operative program of rehabilitation emphasizing strengthening of the hamstrings. The knees were evaluated by testing stability, strength, and range of motion; by roentgenographic examination; and by the patient's level of participation in sports. The patient's uninjured knee was used for comparison. The results showed a high incidence of anterior instability, but no significant differences in degenerative changes or range of motion. All patients returned to some sports participation, with fourteen (59 per cent) returning to their full preinjury level of participation. Higher levels of sports participation were found in the patients whose hamstrings strength was equal to or more than their quadriceps strength.

Infection after Total Elbow Arthroplasty

Abstract: Deep sepsis occurred after fourteen (9 per cent) of 156 elbow-replacement procedures in 140 patients. This high frequency of infection was attributed to several factors. First, the patients were drawn from a population that was at high risk of infection, because rheumatoid arthritis and post-traumatic arthritis were the indications for arthroplasty. Second, many of the patients had had prior surgery, which significantly (p less than 0.02) increased the risk of sepsis in those with rheumatoid arthritis. Third, some patients had surgery after the arthroplasty, which also seemed to predispose to deep infection (p less than 0.05). In one patient the elbow was salvaged by early debridement, and in two others reimplantation of a total joint replacement was successful after removal of the first prosthesis and control of the infection. Resection arthroplasty was required to arrest the infection in ten patients, eight of whom had a satisfactory result. The high incidence of this significant complication attests to the hazardous nature of the elbow-replacement procedure and should warn orthopaedic surgeons to be cautious when recommending this form of treatment.

Legg-Calvé-Perthes disease.

Abstract: In this condition, the upper end of the thigh bone, known as the femoral head, breaks down. As a result, the femoral head is no longer round and does not move easily in the hip socket, which leads to hip pain, limping, and restricted leg movement. The bone eventually begins to heal itself through a normal process called bone remodeling, by which old bone is removed and new bone is created to replace it. This cycle of breakdown and healing can recur multiple times. Affected individuals are often shorter than their peers due to the bone abnormalities. Many people with Legg-Calvé-Perthes disease go on to develop a painful joint disorder called osteoarthritis in the hips at an early age.