Cellular isolation, culture and characterization of the marrow sac cells in human tubular bone.

The goal of this study is to characterize the epithelioid-like human marrow sac cells that separate the myeloid and osteoblast populations in situ and to determine if they express osteoblast cytoplasmic markers. Tubular segments of femoral diaphyseal bone were obtained from healthy young (4-8 yr) male and female patients undergoing femoral shortening surgeries. The interface between bone and marrow was examined by scanning (SEM) and transmission electron microscopy (TEM). The marrow sac cells were isolated and cultured in a-MEM medium with and without dexamethasone, glycerophosphate, and ascorbic acid [DGPA]. Alkaline phosphatase (ALP), bone morphogenetic protein-2 (BMP-2) and osteocalcin were evaluated. In the SEM, the marrow sac presented a distinctive pattern of large overlapping cells. TEM studies showed that marrow sac was one or two cells thick, which were attenuated with elongated nuclei, few cellular organelles, and appeared to display intercellular gap junctions. In culture, the marrow sac cells stained positively for ALP and BMP-2, and their expression was enhanced two- to three- fold when the cells were grown in DGPA. DGPA did not enhance osteocalcin expression. The cells of the human marrow sac reside proximate to endosteal osteoblasts and express osteoblastic markers. It is possible that these stromal cells constitute an osteoprogenitor pool from which replacement osteoblasts are recruited, and that they are involved in normal bone formation and in bone diseases (e.g., osteoporosis and osteopenia).

Vulpius and Z-lengthening.

An evaluation of ankle function in gait after 22 Vulpius lengthenings of the gastrocnemius fascia and 27 Z-lengthenings of the Achilles tendon was performed in 33 ambulatory cerebral palsy patients. Simultaneous hip or knee surgeries or both were performed in most instances. Gait analysis including ankle motion, moment, and power data was obtained before surgery and approximately 1 year after. The ankle moments were improved and approached normal in the majority of cases in each group. There were no significant differences between the Vulpius and Z-lengthening groups at follow-up in any of the parameters. There were significant differences between the initial and follow-up measurements of each group. The Vulpius group showed a notable presence of abnormal midstance work initially and had a significant decrease at follow-up. The Z-lengthening group showed a notable presence of equinus and a notable lack of push-off work initially and had a significant decrease in equinus and a significant increase in push-off work at follow-up. Each procedure appears to give satisfactory results because the follow-up results were similar.

A comparison of Wisconsin instrumentation and Cotrel-Dubousset instrumentation.

Twenty-six patients who underwent Wisconsin instrumentation and 36 patients who underwent Cotrel-Dubousset instrumentation (CDI) for idiopathic scoliosis were studied. Inclusion in the study required at least 24-month follow-up. Variables compared included operating time, blood loss, frontal plane correction, axial and sagittal plane changes, effects on compensation, and complications. In general, operating time, blood loss, and instrumentation problems were greater with CDI. Thoracic curve correction in King II curves was better with CDI. There was no advantage to either system with respect to sagittal plane alignment or rotation. When all factors were considered, a significant advantage to use of CDI could not be demonstrated.

Solitary fibromatosis of bone. A rare variant of congenital generalized fibromatosis.

Congenital generalized fibromatosis is part of the spectrum of the fibromatoses of infancy and childhood. The lesions are usually multiple and fibrous in nature. They may appear in virtually every organ outside the central nervous system. Congenital generalized fibromatosis can be limited to the skeleton and rarely manifests itself as a solitary bone lesion. Solitary osseous lesions often behave differently than multiple osseous lesions. Solitary lesions often do not regress without treatment and can have a high incidence of recurrence with less than marginal excision. Multiple osseous lesions often regress without treatment.

Foot-progression angle in clubfeet.

Foot-progression angle was determined using the Shutrack carbon paper system for 52 feet treated by clubfoot release without wide subtalar release and 43 age-matched controls. Mean foot progression angle was -5 degrees for the clubfeet. This represented 13 degrees of inturning from the normal mean of 8 degrees. Forty-eight percent of the clubfeet had inturning greater than 2 SD from the normal mean. The causes of inturning included adductus (p = 0.005) and, in some cases, internal tibial torsion or internal femoral torsion. Varus of the foot was usually associated with inturning, but inturning was not always associated with varus.

Clubfoot release without wide subtalar release.

Fifty-two feet treated by clubfoot release without wide subtalar release were evaluated 4.2-10.8 years after surgery. Eleven feet (21%) had undergone additional operative procedures at the time of review, and 82% of feet had good or excellent functional ratings at that time. The mean talocalcaneal index was 49 degrees (range 12-76 degrees), indicating that correction of the subtalar joint occurred in some patients. This procedure satisfactorily corrects many feet but undercorrects some. Overcorrection was rare. Foot progression angles were also determined and are reported in an accompanying article.

Management of femoral shaft fractures in the adolescent.

Forty-four patients (45 fractures) with open physes (age range 11-16 years) underwent treatment for femoral shaft fractures. Seven malunions occurred in the 24 fractures in the nonoperative group; none occurred in the 21 fractures treated by intramedullary nailing. Hospital stay was significantly shorter in the operatively treated patients. There was no premature growth arrest in the surgical group.

Spinal cord injury without osseous spine fracture.

Sixteen patients with spinal cord injury without osseous spine fracture and 55 patients with spinal cord injury with osseous spine fracture aged from birth through 18 years were studied. Those without osseous fracture were younger (mean age 6 years) than were those with osseous fracture (mean age 16 years). Extravasation of myelographic dye from the spinal canal was a poor prognostic sign. All three in the group with this finding without osseous fracture had complete spinal cord lesions. Those without osseous fracture should be followed for the development of late spinal deformity that may require orthotic support or surgical stabilization.

Disorders of the sacro-iliac joint in children.

The cases of seventeen children whose ages ranged from two to eighteen years and who were treated for a disorder of a sacro-iliac joint between 1975 and 1983 were reviewed retrospectively. Thirteen children were acutely ill, with a temperature of more than 38 degrees Celsius, and four had chronic symptoms that had persisted for three weeks to one year. Pain in the hip, thigh, and buttock was the most common symptom. Of the thirteen acutely ill patients, eleven had septic arthritis of a sacro-iliac joint, while one who had ankylosing spondylitis and one who had juvenile rheumatoid arthritis had acutely painful arthritis of a sacro-iliac joint. Of the four patients who had chronic symptoms, two had septic arthritis of a sacro-iliac joint; one, ankylosing spondylitis with sacro-iliac involvement; and one, eosinophilic granuloma of the ilium. Thus, thirteen patients had septic arthritis of a sacro-iliac joint and four had some other disorder. For the seventeen children who had acute or chronic symptoms, at admission the white blood-cell count ranged from 3,500 to 26,200 per cubic millimeter (average, 11,100 per cubic millimeter) and the sedimentation rate, as determined by the Westergren technique, ranged from twenty-two to sixty-five millimeters per hour (average, fifty millimeters per hour). Twelve of the plain radiographs of the seventeen patients were negative. The initial bone scans of all seventeen patients were positive in eleven and negative in six. Of these six, five had septic arthritis and one, juvenile rheumatoid arthritis. A computed tomographic scan was performed in four patients and was positive in all of them: three had septic arthritis and one had ankylosing spondylitis. Organisms were cultured successfully from blood, from material aspirated from the sacro-iliac joint, or from stool of all thirteen patients who had sepsis. The thirteen infections responded well to appropriate antibiotics, which were administered intravenously to seven patients and first intravenously and then orally to six.

Segmental spinal instrumentation with sublaminar wires. A critical appraisal.

Fifty-eight patients who had scoliosis or kyphosis of varying etiologies were followed for a minimum of two years (average, forty-four months) after segmental spinal instrumentation using sublaminar wires. In eight (19 per cent) of the patients who had been operated on for scoliosis one or both rods broke. The average time that had elapsed before the breakage was discovered was twenty-three months. None of the patients in whom a rod had broken had had postoperative immobilization or a first-stage anterior fusion, and only one had had supplementary grafting with banked bone. Instrumentation to the pelvis was also associated with a greater incidence of broken rods. The use of supplementary grafting with banked bone or the use of postoperative immobilization significantly decreased the loss of postoperative correction. Preliminary anterior spinal fusion helped prevent breakage of rods but not loss of correction. It was concluded that postoperative immobilization and use of large amounts of supplementary bone graft lead to better results when using this implant system.

Effects of neurodevelopmental treatment on movement patterns of children with cerebral palsy.

Twelve children with mild, moderate, or severe cerebral palsy were examined and videotaped before and after an intensive course of physical therapy in a neurodevelopmental treatment course. These tapes, demonstrating various predetermined movement patterns, were then randomized and viewed by six evaluators. None of the evaluators could tell the difference between before and after films. This demonstrated that significant changes were not seen in children with cerebral palsy after 6 weeks of therapy.