Effect of intermittent administration of parathyroid hormone on fracture healing in ovariectomized rats.

The effects of intermittent administration of parathyroid hormone on fracture healing in ovariectomized rats were examined to evaluate its potential use as a therapeutic agent for osteoporotic fractures. Three months postovariectomy, bilateral tibial shaft fractures were induced and stabilized by intramedullary nailing with Kirschner wires. Saline, 17beta-estradiol (Sigma Chemical Corp, St Louis, Mo), or recombinant human parathyroid hormone (1-84) (Korean Green-Cross Pharm Corp, Seoul, Korea) was given once a day for 30 consecutive days during fracture healing. Fracture healing was assessed by morphometric and mechanical analysis of fracture callus. Intermittent parathyroid hormone administration increased the morphometric and mechanical parameters in a dose-dependent manner. A bone-resorption inhibiting agent, 17beta-estradiol did not offer advantage in terms of fracture healing in ovariectomized rats. Findings suggest intermittent parathyroid hormone administration may benefit osteoporosis and fracture.

Comparison of 1- and 2-incision posterior cruciate ligament reconstructions.

This study compared the results of the 1-incision technique and the conventional 2- incision technique for the arthroscopic treatment of the posterior cruciate ligament (PCL) injury. The 2-incision technique was performed in 10 patients (group I) and the 1-incision technique in 45 patients (group II). The average duration of follow-up was 45 months in group I and 36 months in group II. Bone-patellar tendon-bone (BTB) autografts were used for all patients in group I. In group II, 34 BTB autografts and 11 BTB allografts were used. Postoperative Lysholm mean values were 90.0 in group I and 90.6 in group II. HSS mean values were 87.7 in group I and 92.6 in group II (P = .037). The Tegner activity level scales were 6.4 in group I and 6.5 in group II. The average side-to-side difference of the corrected posterior translation measured by the KT-2000 arthrometer were 2.10 mm in group I and 2.38 mm in group II. There were no statistically significant differences between the 2 groups in postoperative mean values except HSS scores. The arthroscopic PCL reconstruction using the 1-incision technique showed good results comparable with the conventional 2-incision technique. This technique needs no another incision or dissection over the medial femoral condyle.

Effect of intermittent administration of parathyroid hormone on fracture healing in ovariectomized rats.

To evaluate the potential use as a therapeutic agent for osteoporotic fractures, we examined the effects of intermittent administration of parathyroid hormone on fracture healing in ovariectomized rats. At three months post-ovariectomy, bilateral tibial shaft fractures were induced and stabilized by intramedullary nailing with Kirschnerwires. Saline, 17-estradiol, or recombinant human PTH(1-84) was given once a day for 30 consecutive days during fracture healing. Fracture healing was assessed by morphometric and mechanical analysis of fracture callus. Intermittent parathyroid hormone administration increased the morphometric and mechanical parameters in a dose-dependent manner. 17-estradiol, a bone-resorption inhibiting agent, did not offer advantage in terms of fracture healing in ovariectomized rats. Our findings suggest that intermittent parathyroid hormone administration may benefit osteoporosis and fracture.

Prevention of malrotation deformity in femoral shaft fracture.

OBJECTIVE: To confirm the need to check anteversion (AV) of the intact femur to prevent malrotation deformity following intramedullary nailing in femoral shaft fracture. DESIGN: Prospective. RESULTS: Four patients out of forty-two (forty-three nailings) developed malrotation deformity of more than 15 degrees after femoral nailing. In the second part of the study, distal fragments of the fractured femurs were rotated 13.8 degrees on average to match with the rotational alignment of the intact femur. The malrotation deformity was controlled to less than 5 degrees in all cases. Closed reduction along the longitudinal axis of the femur was performed and was acceptable in forty-two cases (thirty-four cases in Part 1 of the study and eight cases in Part 2) prior to nailing. The coefficient of correlation between preoperative and postoperative AVs was 0.73 in these cases. CONCLUSION: Because true neutral rotation of the distal fragment alone is not accurate in preventing malrotation deformity of the femur following intramedullary nailing, we recommend measuring AV in both intact and fractured femurs and correcting rotational malalignment if it exists at the time of femoral nailing. Rotational alignment did not change significantly unless we failed to externally reduce the fracture due to a flexion deformity of the proximal fragment.

Modified step-cut osteotomy of the humerus.

Corrective osteotomy of the distal humerus for a posttraumatic cubitus varus was performed in 31 patients using a modified step-cut osteotomy. The average patient age was 14.3 years. Complete bony union was obtained between the 8th and 16th weeks. Twenty-one patients achieved excellent results, 7 achieved good results, and 3 achieved poor results on the basis of Oppenheim's criteria. Although the results for 28 patients (90.3%) were classified as excellent or good, 6 patients (19.3%) were subjectively disappointed due to bulging of the lateral condyle. We achieved an overall improvement in mechanical stability and established an easier technique in corrective osteotomy. However, this approach may not be appropriate if the correction angle desired is greater than 30 degrees.

Immediate ipsilateral fibular transfer in a large tibial defect using a ring fixator. A case report.

Massive segmental bony defects in open tibial fractures are generally treated with conventional bone grafting, a free vascularised fibular graft or the ring fixator technique. A vascularised fibular graft may be superior to a conventional bone graft, but it is technically difficult and occasionally impossible. In such circumstances, fibular transfer in conjunction with a ring fixator is an alternative method. This procedure can be accomplished by transferring the osteotomised part of the fibula to the tibia by means of olive wires. The authors have treated a 20-year-old male who presented with a Gustilo type IIIB open tibial fracture. The soft tissue defect was severe, only the tibialis posterior artery was patent and the peroneal artery was partially damaged. A latissimus dorsi flap was performed to cover the soft tissue defect. Since the patent tibialis posterior artery had already been used for the flap, it was difficult to perform a vascularised fibular graft. Moreover, it was technically difficult to accomplish a gradual transport using a ring fixator because the distal tibia was lost. For this reason, the fibular transfer was performed immediately after the ring fixator was applied. Good bony union and fibular hypertrophy were obtained even though these two procedures were undertaken simultaneously.

Multiple neurilemomas. A case report.

Multiple neurilemomas in diverse locations of the body developed in a 53-year-old woman. The patient had multiple neurilemomas which occurred in the thoracic spine, lumbar spine, retroperitoneal sympathetic chain, sacral nerve root, femoral nerve, both sciatic nerves, radial nerve, and ulnar nerve without evidence of Von Recklinghausen's disease. This is the first well documented report on multiple neurilemomas with whole body distribution.

Arthroscopic transglenoid Bankart suture repair with modifications of Caspari's technique.

Recent advances in arthroscopic surgery have given new options for dealing with anterior glenohumeral instability with less morbidity than the open procedure. The early literature discussing arthroscopic Bankart suture repair is favorable, however limited long-term follow-up studies have yet to prove its success. This study reports our experience with arthroscopic transglenoid Bankart suture repair with a minimum 2-year follow-up. Arthroscopic transglenoid Bankart repair was performed in 23 cases of anterior shoulder instability with some modifications of Caspari's suture technique. First, the suture material was #1 PDS and the number of sutures was 4 or 5. Second, the insertion site of the guide pin was moved to 1 o'clock on the right shoulder and to 11 o'clock on the left shoulder to prevent slippage of the guide pin. With this technique, we obtained 87% satisfactory results analyzed by the Rowe functional grading system. There was no suprascapular or axillary nerve injury. Two patients had redislocations and one patient had recurrent subluxation. Five patients complained of suture-knot irritation problems.

Transforming growth factor-beta 1 responsiveness of human articular chondrocytes in vitro: normal versus osteoarthritis.

The transforming growth factor-beta 1 was known as having the most important influence on chondrocytes among various growth factors, being abundant in articular chondrocytes and osteocytes. We performed in vitro monolayer cultures of human articular chondrocytes from normal and osteoarthritic patients and studied the transforming growth factor-beta 1 responsiveness of those chondrocytes. The cell-growth curve indicated that the primary osteoarthritic chondrocyte culture with transforming growth factor-beta 1 showed a more rapid growth pattern than normal chondrocytes with or without TGF-beta 1 and osteoarthritic chondrocytes without TGF-beta 1. The osteoarthritic group showed a sharp decline in growth pattern with subsequent culture. The shape of osteoarthritic chondrocytes was bigger and more bizarre compared to those of normal chondrocytes. With subsequent culture, this change became prominent. The transforming growth factor-beta 1 increased the [3H]-TdR uptake in each group. The phenotypes of chondrocytes were more clearly expressed in the normal group. The chondrocytes lost their phenotype (production of collagen type II) following subculture in each group. The transforming growth factor-beta 1 could not inhibit or delay the dedifferentiation process (loss of phenotype).

Lengthening of an amputation stump by the Ilizarov technique. A case report.

A woman, 29 years of age, sustained a below knee amputation following injury and was left with a stump 5.5 cm long. Good soft tissue cover was obtained with a myocutaneous flap using the gastrocnemius muscle and heel pad flap from the injured leg. The stump was then lengthened by 7 cm, to 12.5 cm, using the Ilizarov distraction technique. The patient was able to bear weight on the end of the fixator during the 8 months it was in position. The gap filled with bone and there were no complications. She recovered good function.

Treatment of tibial pilon fractures using ring fixators and arthroscopy.

Twenty-one patients with tibial pilon fractures were treated with ring fixators and arthroscopy. There were 2 Type I, 14 Type II, and 5 Type III fractures using the Ruedi classification. In Ruedi Types I and II fractures, ring fixators were applied to the tibia and foot, and closed reduction was performed, monitoring the quality of the reduction with an image intensifier. When the quality of the reduction was questionable, arthroscopy was used, and if necessary, the reduction was readjusted. Olive wires were used to achieve reduction and fixation. In all Ruedi Type III fractures and 4 Ruedi Type II injuries, a limited open reduction was performed instead of arthroscopy. Approximately 8 weeks after the operation, the foot mounting was removed. The ring fixators were removed between 16 and 28 weeks. Bony union was achieved in all but 1. At an average followup of 37 months, there were 15 good, 4 fair, and 2 poor results. There were 8 cases of pin tract infection, and 1 patient had loss of reduction. There were no cases of deep wound infection. It was concluded that ring fixator and adjunctive arthroscopy is safe and effective in the management of tibial pilon fractures.

Measurement of bone mineral density in osteoporotic fractures of the spine using dual energy X-ray absorptiometry.

The authors analyzed bone mineral density (BMD) in 283 postmenopausal and senile women using dual energy x-ray absorptiometry from March 1990 to April 1992. Bone mineral density of the vertebral body in the osteoporotic fracture group was compared with that in the osteoporotic group to investigate the correlation among BMD, age distribution, and fracture type, and to estimate fracture threshold in the osteoporotic fracture group. BMD decreased rapidly (10%) from 50 and 60 years of age and decreased slowly after 60 years of age; osteoporotic spine fractures were found in 98 cases (35%); there was significant difference in BMD between the osteoporotic group and osteoporotic fracture group; there was no spine fracture when BMD was above 1.00 g/cm2; fracture threshold was 0.85 g/cm2 at the 90th percentile; BMD in multiple spine fracture and old fracture groups was lower than in the single and fresh fracture groups and this was statistically significant. We have concluded that when BMD decreases to less than 0.85 g/cm2, the risk of osteoporotic vertebral fractures escalates rapidly. Postmenopausal and senile women with BMD less than this fracture threshold should receive prophylaxis for osteoporotic fracture.

Blood gas and electrolyte changes after tourniquet application in total knee replacement surgery.

The tourniquet is widely used in upper and lower extremity surgery in orthopedic practice. However, safe working guidelines for the application of the tourniquet are not clearly defined. The use of a tourniquet is an important step in performing total knee arthroplasty, and it seems plausible that mechanical damage is directly related to the height and the duration of the pressure of the tourniquet applied. Even the tourniquet pressure which is widely accepted in clinical practice, if it is applied for several hours, would permanently damage not only tissues directly under the tourniquet but also the muscles and the nerves distal to the tourniquet. The resultant ischemia to limb produces local changes including hypoxemia, acidosis and hyperkalemia. Relatively little is known about the systemic effects of tourniquet release when the patient is undergoing total knee replacement surgery under a general anesthesia. Therefore, we studied the systemic effects. The results were as follows: 1) Approximately five minutes after the tourniquet was released there was a statistically significant increase in mean heart rate.: 2) Serum potassium levels tended to increase significantly until five minutes while the serum sodium level rose significantly only one minute, and the lactate level rose significantly for only two minutes after tourniquet released; 3) PaCO2 increased for five minutes after tourniquet release and remained elevated for 30 minutes; 4) PaO2 did not change significantly two minutes after tourniquet release; 5) The mean pH dropped to 7.34 and remained low for over five minutes.

Ossifying fibroma.

Our experience includes seven cases of ossifying fibroma. The condition also appears in the literature under diagnostic names such as congenital fibrous dysplasia, congenital osteitis fibrosa, congenital fibrous defect of the tibia, and osteofibrous dysplasia of the tibia and fibula. The lesions develop in childhood and are located in the diaphysis of the tibia, or fibula. Of seven patients, we performed wide excision with free vascularized fibular graft in five cases, wide resection of the distal one-third of the fibula in one case, and curettage and bone graft in one case. Two of the patients who had wide excision with free vascularized fibular graft had recurrence. One case of recurrence occurred where incomplete wide excision with free-vascularized fibular graft was performed because the lesion was too close to the distal epiphysis of the tibia. One of the patients who had curettage and bone graft also had recurrence. It was concluded that children who have an ossifying fibroma requiring surgery can safely be treated with wide excision with or without free-vascularized fibular graft.

Assessment of bone mineral density in postmenopausal and senile osteoporosis using quantitative CT.

The authors analyzed bone mineral density in 213 patients from January 1988 to September 1989. Bone mineral density of the vertebral body in the osteoporosis group of patients was compared with that in the normal group to investigate the correlation between bone mineral density and age distribution, and to estimate fracture threshold in the osteoporosis group. It was found that men, by linear regression, lose an average of 0.91% of bone per year, and women, by cubic regression, lose an average of 1.14% per year, accelerating at menopause. In the osteoporotic group, bone mineral density of men decreased an average of 29.7% compared with the non-osteoporotic group; that of women decreased an average of 29.9%. There was no difference between sexes. The fracture threshold of the osteoporotic patient was estimated to be about 90 mg/cm3.

Piriformis syndrome--a case report.

Piriformis syndrome, a term applied to an abnormal condition of the piriformis muscle, is characterized by symptoms and signs due to sciatic nerve entrapment at the greater sciatic notch. Recently we reviewed a case of unusual low back pain, radiating to the left lower extremity with tenderness particular in the left buttock. The patient was successfully treated by sectioning the piriformis tendon. We described the clinical features of a case of piriformis syndrome and reviewed the foreign literature.