A flap augmentation technique for Achilles tendon repair. Postoperative strength and functional outcome.

The efficacy of tendo-Achilles rupture repair by a modified version of Lindholm's technique was studied biomechanically and functionally. The procedure involves secondary reinforcement of a conventionally reapproximated rupture site by means of a backfolded augmentation flap. The flap cross section consisted of approximately one third of the proximal stump. In 18 paired fresh anatomic Achilles tendons, flap augmentation repairs had an average strength of 217.5 N (SD = 44.7), whereas conventional repairs (two interrupted Kessler sutures) failed at an average of 153.9 N (SD = 30.2). In a series of seven augmentation flap patients evaluated clinically and by Cybex dynamometry, an excellent result (by the Percy/Conochie rating) was obtained in six, and a good result in one. Plantar flexion strength in full extension averaged 94% of that of the uninvolved leg. There were no reruptures. These data suggest that flap augmentation may be a useful adjunct to conventional suture repair.

Early casting of femoral shaft fractures in children.

Twenty-six children with fractures of the femur were entered into a prospective study to determine the efficacy of treating certain of these fractures by early spica cast immobilization. They were compared with 50 consecutive patients with similar fractures who were treated prior to the study to determine the potential cost savings and decrease in patient days in hospital. The clinical results of treatment were compared with results from the literature and the previous group where applicable. Our conclusion from this study is that most femoral shaft fractures in children under 10 years of age can be treated by closed reduction and early spica cast immobilization with results that are at least as good as those achieved by conventional methods, and with a 70% savings in hospital cost. Factors such as obesity, swelling, shortening, comminution, and fracture type can all combine to give relative contraindications for the use of this technique.

Localised immune complexes and slipped upper femoral epiphysis.

Slipped upper femoral epiphysis remains a disease of unknown aetiology. Recent evidence has bolstered speculation that the immune system may play a role in the aetiology or pathogenesis of slipped epiphysis or of one of its complications, chondrolysis. This study reports the finding of immune complexes in the synovial fluid of all but one hip affected with slipped epiphysis in a consecutive series. In seven patients, immune complexes were detected by both the Raji cell assay and C1q-binding assay; in two, by the C1q-assay only; and in one, by the Raji cell assay only. No patients had immune complexes in the serum. Twenty-one patients with synovitis of the knee or hip caused by a variety of disorders served as the control group. Two of these patients had immune complexes in their synovial fluid. It appears that the immune complexes characterise the synovitis found with slipped upper femoral epiphysis as distinct from most other synovitides.

Synovial immunofluorescence in patients with slipped capital femoral epiphysis.

To evaluate if the immune system is active in slipped capital femoral epiphysis (SCFE) or chondrolysis, 16 patients with SCFE were studied by evaluation of their serum immunoglobulins, histology of their synovium, and immunofluorescent staining of their synovium. Patients with Perthes' disease, chondromalacia patellae, septic arthritis, sickle cell disease, and torn meniscus were controls. Serum immunoglobulins were normal in all patients. The histology demonstrated synovitis in all patients except in one normal knee. Plasma cells were a prominent feature of the synovitis in the patients with SCFE. Three patients had positive synovial immunofluorescence for IgG and C3. Two of these patients subsequently developed chondrolysis and one did not. One additional patient who had negative synovial immunofluorescence developed chondrolysis. It is postulated that the immune system is active in some patients with SCFE, but what, if any, role it plays in the disease or its complications remains to be shown.