Patellar tendon rupture. Description of a simplified operative method for a current therapeutic problem.

A simple operative method for the treatment of patellar tendon rupture is introduced. The operative procedure is described and we present the short-term results of the first seven patellar tendon ruptures that have been treated accordingly at our clinic. The technique is easily reproducible and utilizes a minimum of foreign body implant. A secondary procedure for removal of suture material is rarely necessary.

Paget's disease of bone.

Paget's disease of bone is defined as a process of increased bone remodeling; the primary event is increased resorption (osteoclastic activity) followed by subsequent reactive bone formation (osteoblastic activity). It is usually asymmetric and may be asymptomatic. The etiology is unknown, but recent evidence appears to support the theory that a virus is an important etiologic factor. It may present with a wide variation in the clinical and radiographic picture. The most frequent sites of involvement include the spine, femora, cranium, pelvis, and sternum. The most common complaints are pain, skeletal deformity, and change in skin temperature. Pathologic fractures may be the presenting manifestations or complications in a patient with known Paget's disease. They occur most frequently in the long weight-bearing bones of the lower extremities such as the femoral neck and subtrochanteric and tibial regions. The two major therapeutic agents available for treatment are calcitonins (porcine, salmon, or human) and diphosphonates. The aim of such therapy is to control the metabolic activity of the disease, to normalize the biochemical parameters, and to improve the symptoms. Fortunately, tumors are rare; early diagnosis may give rise to more effective palliation, if not a significant cure rate.

Paget's disease of bone.

Paget's disease of bone is defined as a process of increased bone remodeling; the primary event is increased resorption (osteoclastic activity) followed by subsequent reactive bone formation (osteoblastic activity). It is usually asymmetric and may be asymptomatic. The etiology is unknown, but recent evidence appears to support the theory that a virus is an important etiologic factor. It may present with a wide variation in the clinical and radiographic picture. The most frequent sites of involvement include the spine, femora, cranium, pelvis, and sternum. The most common complaints are pain, skeletal deformity, and change in skin temperature. Pathologic fractures may be the presenting manifestations or complications in a patient with known Paget's disease. They occur most frequently in the long weight-bearing bones of the lower extremities such as the femoral neck and subtrochanteric and tibial regions. The two major therapeutic agents available for treatment are calcitonins (porcine, salmon, or human) and diphosphonates. The aim of such therapy is to control the metabolic activity of the disease, to normalize the biochemical parameters, and to improve the symptoms. Fortunately, tumors are rare; early diagnosis may give rise to more effective palliation, if not a significant cure rate.

Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation.

Twenty-four patients had a severe open fracture of the tibia that was initially treated by external fixation and subsequently by reamed intramedullary nailing. The external fixation had been maintained for an average of fifty-two days (range, seven to 230 days). The mean interval between removal of the external fixator and intramedullary nailing was sixty-five days (range, three to 360 days). In five of the seven patients who had had an infection at one or more of the pin sites, an infection later developed around the intramedullary nail. In comparison, only one of the seventeen patients who had not had a pin-site infection had an infection later around the nail (p = 0.003). An analysis of other variables, including the duration of external fixation, wound coverage, other injuries, and the type of fracture, showed that none was a predictor of infection either at the pin sites or around the intramedullary nail. We concluded that a pin-site infection that develops during external fixation is a contraindication to the subsequent use of reamed intramedullary nailing in patients who have a fracture of the tibia.

Rotational stability of diaphyseal fractures of the radius and ulna fixed with Rush pins and/or fracture bracing.

The rotational stability of fractures of the radius and ulna treated with Rush pins and/or fracture bracing was studied in six fresh cadaver forearms. Forearm rotation and fracture site motion (rotation) were measured as functions of applied forearm torque and rotation (pronation-supination). Values were obtained from the forearm: (1) intact and with both bones fractured; (2) without fixation; (3) with a fracture brace; (4) with Rush pins; and (5) with a combination of Rush pins and a fracture brace. A brace was ineffectual in reducing fracture site motion when the wrist was rotated to specified angles compared to fracture site motion for the forearm with no fixation treatment rotated to the same angles. When loading to specific torque levels, however, the brace reduced fracture site motion to one-half the motion with no fixation treatment. Under both loading conditions, Rush pin fixation significantly and markedly reduced the fracture site motion (to approximately one-eighth of the motion with no fixation treatment), whereas a brace in conjunction with Rush pins did not significantly further reduce the fracture site motion. The radius showed more motion at fracture site than the ulna.

14-year follow-up study of a patient with massive calcar resorption. A case report.

The authors present an in-depth clinical, radiographic, and pathologic analysis of a 62-year-old man with massive bone reabsorption around the proximal femur in a total hip arthroplasty (THA). The THA was revised 13 years after implantation. Thirty millimeters of calcar resorption was noted radiographically. Evidence of stem bending was present on examination of the femoral implant, and marked wear of the acetabular cup was noted. The pathologic evaluation of removed calcar bone and cement revealed a histiocytic mass invading the bone. Intracellular and extracellular polymethylene debris was noted within the invasive mass. Evidence of fragmented methylmethacrylate cement was also present. The bone-cement interface in the excised calcar region contained segments that showed active bone remodelling around the cement without an interposed membrane. It is possible that this case of calcar resorption began with histiocytic activation and recruitment by polyethylene wear debris followed by active bone lysis. The process may be perpetuated by the fragmentation of cement, as motion occurred at the calcar bone-cement interface, and may represent an extreme example of a process occurring in cases of calcar resorption in general.

Patellar dislocation following total knee replacement.

The reported incidence of patellar problems after total knee replacement has ranged from 5 to 30 per cent. Patellar dislocation is infrequent but can cause disabling symptoms. Between January 1974 and May 1982, eleven patients (twelve knees) with symptomatic lateral dislocation of the patella after total knee replacement were treated at The Hospital for Special Surgery by realignment of the extensor mechanism. All of the patients were women. Their average age was sixty-two years and average weight, eighty-seven kilograms. The diagnosis was osteoarthritis in seven knees and rheumatoid arthritis in five. Most of the patients had had preoperative valgus deformity (average, 18 degrees). The cause of dislocation was trauma in three knees, incorrect tracking of the patella after replacement in six, and malrotation of the tibial component in three. Four different prosthetic designs had been used. The design of the implant did not appear to be a factor causing dislocation in this group. The patellar dislocation was treated by proximal realignment of the quadriceps in ten knees, lateral retinacular release alone in one, and revision of the tibial and femoral components combined with proximal realignment in one. After an average follow-up of thirty-four months (range, twenty-four to fifty-seven months), the results according to The Hospital for Special Surgery knee-rating scale were excellent in ten knees and good in two, and there had been no redislocations.

Giant cell reparative granuloma in the hand: report of three cases and review of the literature.

Occurrence of giant cell reparative granuloma (GCRG) outside the jaw, skull, or facial bones is unusual. Three recent cases of GCRG occurring in the hand are presented. This lesion appears on radiographs as a lucent, expansile defect in bone, similar in appearance to enchondroma, giant cell tumor of bone, aneurysmal bone cyst, or brown tumor of hyperparathyroidism. Histologically, GCRG is characterized by spindle-shaped, fibroblastic stoma with scattered, small, angulated giant cells and areas of osteoid formation around foci of hemorrhage. Establishing the pathologic diagnosis is frequently difficult. Misdiagnosis occurred in approximately half of the reported cases and in one of our cases. The typical clinical presentation is that of localized pain and swelling. GCRG is not a neoplastic disorder; however, it recurred locally in a third of the reported cases. Recommended treatment for GCRG is thorough removal of the diseased tissues and grafting of autologous bone.

Current concepts of Paget's disease of bone.

Paget's disease of bone is a process of increased bone remodeling resulting in architecturally abnormal bone that may affect any area of the skeleton. Paget's disease may present with a wide variation in the clinical and radiographic picture. When symptoms arise, they depend on the site and the extent of skeletal involvement. The two major therapeutic agents available for medical treatment are calcitonin and diphosphonate. Surgical intervention in Paget's disease is indicated for (1) selected fractures, (2) severe disabling arthritis, and (3) extreme bowing deformities causing malalignment of weight-bearing joints.

Total hip replacement for Paget's disease of the hip.

We reviewed our experience with total hip replacement for coxarthrosis due to Paget's disease. The clinical and radiographic results in twenty-one patients who had a total hip replacement between October 1972 and February 1982 were analyzed. The ages of the patients averaged 68.6 years (range, fifty-seven to eighty years) and there were twelve women and nine men. The follow-up averaged five years and two months (range, two years to eleven years and four months). A good or excellent result was achieved in eighteen patients. Of the other three patients, two required a revision operation at two and one-half and five years postoperatively for symptomatic mechanical loosening of the femoral component. The remaining patient had a fair result because of activity of the Paget's disease. Special problems that we encountered included varus deformity of the proximal end of the femur predisposing to varus placement of the femoral component, protrusio acetabuli, increased blood loss, sclerotic bone that made reaming difficult, and heterotopic ossification.