A clinical and histologic analysis of failed fresh osteochondral allografts.

Fresh small osteochondral allografts were implanted in 108 patients. A clinical and histologic analysis was undertaken in 18 patients whose grafts failed and were excised. Twelve of these patients had evidence of viable hyaline cartilage despite adverse conditions. If careful attention is given to patient selection, age, appropriate timing for correction of alignment, and meticulous technique associated with graft positioning, size, and thickness, then the incidence of clinical failure should be minimized.

Distal femoral varus osteotomy for valgus deformity of the knee.

Twenty-four patients who had degenerative arthritis of the lateral compartment of the knee that was associated with a valgus deformity and a superolateral tilt of the joint line were treated by distal femoral varus osteotomy. A surgical technique that was designed to produce a horizontal joint line and a tibiofemoral angle of zero degrees is described. At an average length of follow-up of four years, twenty-two of twenty-four patients had a successful result as judged by our protocol for evaluation. One osteotomy had to be revised for failure of fixation, and one patient had a pulmonary embolism that had a satisfactory outcome after the administration of anticoagulants. One patient required manipulation of the knee at six months. The simple surgical technique that we used was effective in realigning the femoral with the tibial axis in patients who had a valgus deformity of the knee, a superolateral tilt of the joint line, and osteoarthritis of the lateral compartment.

Keller arthroplasty: a prospective review.

A prospective study of the Keller procedure for hallux valgus was carried out on 44 female patients (75 feet) with an average age of 66 years. The average follow-up was 31 months (range, 12-64 months). The operation was effective in improving symptoms (joint pain and bunion tenderness), cosmesis, function (footwear and level of activity) and in decreasing the deformity. The operation did not have an influence on metatarsal calluses. Cock-up deformity was common postoperatively but did not affect the results. The overall patient satisfaction rate was 77%.

Arthroscopic treatment of osteochondral lesions of the talus.

In a study of twenty-four patients (twenty-four ankles) with a symptomatic osteochondral lesion of the talus, eighteen of the lesions were found to be associated with trauma. The lesions were evaluated both radiographically and by arthroscopy. The method of treatment was determined at arthroscopy by observing the nature of the articular cartilage overlying the lesion. The cartilage was graded from I to III based on its appearance. It was found that a lesion can progress from grade I to grade III while under observation. There was a lack of correlation between the radiographic appearance and the findings at arthroscopy. The results after an average length of follow-up of thirty months (range, twenty to forty-four months) indicated that osteochondral lesions over which the cartilage is intact (grade I) are best treated by simple restriction of sports activities. Lesions in which the overlying cartilage is soft (grade II) can be treated through the arthroscope by drilling and those in which the overlying cartilage is frayed (grade III) can be treated through the arthroscope by curettage, with minimum morbidity and good results.

Asymmetric epiphyseal distraction in treatment of Blount's disease.

A 10-year-old boy with Blount's disease was treated by asymmetric distraction of the proximal tibial epiphysis to correct varus deformity of 12 degrees. Gradual hemichondrodiastasis with immediate mobilization resulted in slight overcorrection of the deformity with no complications.

Ski injuries in 1976-1982: Ybrig region, Switzerland.

An analysis is presented of 1763 consecutive injuries that occurred in the Ybrig region in Switzerland, a ski resort, during the 1976-1982 ski seasons. The study included all persons injured while skiing and treated at the emergency care facility at the base of the Ybrig region. Fractures were the most frequent injury. Over the years, a decrease in the total number of injuries was noticed. The severity of the injuries was increased. More attention should be paid to the individual preparation of the skier.

Ankle arthroscopy.

Arthroscopic assessment of the ankle joint can be an important diagnostic aid for intra-articular pathologic conditions. The major portals of entry are anteromedial and anterolateral. In one patient with loose bodies of the ankle, the authors successfully localized the loose bodies and determined the status of the articular surface by arthroscopy. In a second patient with pain and a roentgenogram suggestive of an osteochondral fracture, arthroscopic evaluation determined that the articular surface was intact, and the patient was successfully treated non-surgically. Precise indications for arthroscopy of the ankle have not yet been determined, but its role will certainly be less extensive in the ankle than in the knee.

Lower limb injuries in parachuting.

Parachuting injuries commonly result from inaccurately performed landing. Alteration of the vertical force absorption pattern to a rotational one is suggested as their major cause. Special attention to the flexed body position and adduction of the lower limbs while gliding and landing can prevent those injuries.

Use of radionuclide method in preoperative and intraoperative diagnosis of osteoid osteoma of the spine. Case report.

A 24-year-old man with persistent low back pain and right sciatica, was found to have an osteoid osteoma of the right pedicle of the second lumbar vertebra. 99mTc-MDP bone scan and CAT scan produced an early diagnosis of the lesion. Intraoperative 99mTc-MDP in vitro combined with imaging and quantitative activity measurements were useful for accurate localization and complete removal. The method is simple and can be performed in every nuclear medicine department, with no need for special operating room facilities.

A new orthopedic fixation method in the treatment of bladder extrophy.

Extreme diastasis of the pubis and malalignment of both ilium and hip joints are always associated with the absence of infraumbilical structures and with the failure of the anterior bladder wall to close. Therefore, for a successful cure of extrophy, the pelvic ring has to be repaired, at the time of or a few days prior to the surgical cure of the bladder. The repair of the pelvis, when executed in poor aseptic conditions, results in difficult nursing problems, and fails due to the lack of convenient fixation. For these reasons, we transformed Bartons tongues into an external fixator which enhanced and improved the controlled contention of the "vertical bilateral posterior osteotomy" of the pelvis. When a two stage procedure is decided on, the modified Bartons tongues do not interfere with the urologic surgery, and in addition, the nursing problems are alleviated. Although we have used our modified Bartons tongues in only three cases, our methodology is of low enough risk for it to be reported at this time.

Intraoperative nerve fascicle identification using choline acetyltransferase: a preliminary report.

One reason for failure of nerve recovery after suture or nerve grafting is the inappropriate matching of motor and sensory fibers. Methods used in attempting to solve this problem have either been unprecise, too time consuming, or unpleasant to the patient. Both experimentally and on cadaver samples, the level of choline acetylase activity is eight times higher in motor nerve fascicles than in sensory fascicles. In experimentally cut nerves, the ChAC activity remained high even after a period of 45 days. Thus it was possible to identify both ends of the motor and sensory fascicles in fresh injuries, and the proximal parts in old injuries. We have since used this method of intraoperative nerve identification in three patients. It has proved to be a rapid (70-80 minutes), viable technique for the immediate differentiation between proximal parts of motor and sensory nerve fascicles in cases of old nerve injuries. In contrast to our animal studies we found that the ChAC activity in the distal segment was still different for the various fascicles five months after transection. Presumably the present need for distal exploration to identify the "target organ" can be avoided.

[Fractures of the lateral malleolus with interposition of the medial collateral ligaments]. / Fracture isolée de la malléole externe avec interposition du ligament latéral interne de la cheville.

The authors have observed 10 cases of isolated fracture of the lateral malleolus associated with rupture and interposition of the medial collateral ligament. It was concluded that this type of lesion should not be treated conservatively. The ligament should be surgically repaired and the malleolus fixed. The results were excellent in 9 cases out of 10.

The clinical importance of factor XI deficiency in an Ashkenazi Jewish patient.

Factor XI (PTA) deficiency, a coagulopathy, has been found to be relatively common in Ashkenazi Jews. Clinically it may manifest itself by varying forms of hemorrhage including postoperative bleeding. It is recommended that all Ashkenazi Jews have a partial thromboplastin time (PTT) coagulation test before surgery in order to rule out this coagulopathy, and if the PTT is abnormal a Factor XI assay should be done to confirm the diagnosis and ensure that proper therapy can be provided. A surgical case is presented with its ensuing complications resulting form lack of such information.

Osteochondral graft in the treatment of osteonecrosis of the femoral condyle.

A 65-year-old woman with spontaneous osteonecrosis of the medial femoral condyle of the left knee was treated by a fresh cadaveric osteochondral bone graft. The latest follow-up examination at 2.5 years demonstrated good functional results, as well as radiographic evidence of satisfactory consolidation with no aseptic necrosis or osteoarthritis.