The Boytchev procedure for recurrent anterior dislocation of the shoulder. A controversial technique.

In the Boytchev technique the conjoined tendons of the coracobrachialis and short head of the biceps, together with the tendon of the pectoralis minor and the detached tip of the coracoid process are rerouted behind the subscapularis muscle, and reattached to the coracoid process with a screw. During a 10-year period 37 patients with recurrent anterior dislocation underwent a Boytchev procedure. Twenty-six patients (with 27 shoulders) were available to follow-up. The results of this retrospective study were disappointing, as the overall redislocation rate was 44%. The opinions of other authors were found to be extremely divergent.

Dystrophic kyphoscoliosis in neurofibromatosis type I: a report of two cases and review of the literature.

We report two cases of dystrophic scoliosis in neurofibromatosis, each of particular interest. In the first, kyphosis was present with vertebral rotatory subluxation but no neurologic impairment, while the second patient showed manifest paraplegia due to rapidly progressive kyphoscoliosis. The importance of early surgical stabilisation, both front and back if possible, is stressed. Very sharp curves with progressive myelopathy should not be treated with halo-femoral traction because of the potential danger of evoking permanent paraplegia.

The hung up shoulder: anterior subluxation locking in abduction.

The hung up shoulder, or anterior subluxation locking in abduction, is a bizarre clinical picture which is not frequently seen. It is probably due to the fact that, in the subluxed position, the subscapularis muscle becomes an abductor, rather than an internal rotator. External rotation might shift the subscapular muscle fibres towards the proximal aspect of the humeral head, while joint laxity favors subluxation. It is possible that the hung up shoulder is just one aspect of multidirectional shoulder instability, given the tendency to generalised joint laxity, the frequent autoreduction, the positive sulcus sign, and initiation of subluxation by either abduction-external rotation or extension. In this series three out of four patients were treated conservatively and performed well in daily life; however, only the fourth patient had almost unlimited access to sports, thanks to surgical stabilization.

Septic arthritis of a lumbar facet joint and a sternoclavicular joint.

STUDY DESIGN: This is a case report. OBJECTIVES: To the authors' knowledge, simultaneous septic arthritis of a lumbar facet joint and another joint has not been described as yet. Therefore, a patient is presented in whom both a lumbar facet joint (L4-L5 on the right) and a sternoclavicular joint were involved. SUMMARY OF BACKGROUND DATA: Septic arthritis of a lumbar facet joint is a rare condition, and only a few cases have been reported in the literature. METHODS: The etiology, clinical presentation, technical examinations, and treatment are reviewed. RESULTS: Antibiotic treatment was sufficient to heal these lesions. CONCLUSION: Antibiotic treatment was sufficient to heal these lesions.

Tumour-induced rickets: a case report and review of the literature.

UNLABELLED: Hypophosphataemic rickets was diagnosed in a 6-year-old boy with a negative family history. After 16 years of medical treatment he developed a malignant sarcoma of the right distal thigh. Removal of the tumour by high amputation of the leg resulted in disappearance of the phosphate leak. In spite of surgery and chemotherapy, the patient died due to extensive lung metastases. Retrospective analysis of the initial X-ray films showed a benign lesion on the lateral side of the right distal femur. This lesion is believed to be at the origin of the rickets. This is the first paediatric case reported with malignant degeneration of a benign tumour causing rickets. CONCLUSION: Patients with the classical hallmarks of X-linked, familial hypophosphataemic rickets but no affected family members should have a careful periodic search for a tumour, even years after onset of the disorder.

Osteogenic sarcoma in children. A retrospective study of 58 cases.

Fifty-eight children between age 6 and 18 years were treated for osteogenic sarcoma in the period 1962 to 1987. Fifty-one patients with no preoperative pulmonary metastases (group A) had an overall 5-year survival rate (T5) of 41%; they were subdivided into three subgroups. In subgroup A1 treated with surgery and/or radiotherapy (15 cases), the 5-year survival rate (T5) was 33.3%, as in the classical historical series. In subgroup A2 treated with surgery and postoperative chemotherapy (19 cases) the T5 was 38.8%. In subgroup A3 treated by surgery and pre- and postoperative chemotherapy (17 cases) the T5 was 66.6%, which was statistically the best therapy (p < 0.5). This confirms the general trend in orthopedic oncology. Further data proved the negative prognostic value of male sex, while the grade of tumor and the surgical margins were important factors, but not statistically significant. Seven patients with preoperative metastases (group B) had a T5 of 0%.

Vertebral aspergillosis. A case report and review of the literature.

A case of Aspergillus osteomyelitis of the spine is presented and the world literature is reviewed, for a total of 32 cases. Aspergillus osteomyelitis is rare, but the spine is most frequently affected. It can be induced hematogenously, by contiguity or by direct inoculation. Up to now medical treatment has been based on amphotericin B, but its toxicity is problematic. Itraconazole and fluconazole do not have this shortcoming. Additional surgery has been advocated in the past. In the present series combined medical-surgical treatment (20 cases) led to a higher survival rate (70%) than medical treatment (12 cases: 58%), but neurological recovery was much more frequent in the second group (40% versus 13%).

Surgical treatment of spinal metastases: long-term follow-up.

Very few studies provide clear long-term results after anterior decompression-stabilization for vertebral metastases. When they do, they fall into two groups: a first group, claiming about 80% of favorable and lasting neurological results, and a second group, which admits progressive deterioration, sometimes after an initial improvement. The present series belongs to the second group. It consists of 22 patients, 17 of whom underwent anterior surgery. Laminectomy was not performed (except one hemilaminectomy at C6). The reason for the divergent results is not immediately clear. A plea is made for a universal scoring system, to be used at regular intervals, which might provide a more objective look at the results. Last but not least, radiation therapy should always be considered first.

Chromosome changes in a case of hibernoma.

Cytogenetic analysis of a rare adipose tissue tumor, hibernoma, a benign proliferation of the brown fat, is presented for the first time. A complex translocation involving bands 1p36, 2q33, 5q22, and 11q13 was found as the sole chromosome abnormality.

Evaluation of 99mTc-mercaptoacetyltripeptides in mice and a baboon.

Different derivatives of MAG, carrying amino acids such as D- or L-alanine, D-serine, D-2-aminobutyric acid, D-valine or D-phenylglycine were synthesized and their 99mTc-complexes were evaluated in mice and a baboon. The efficiency of renal handling of the examined 99mTc-complexes is influenced not only by their lipophilicity but also to a great extent by their configuration and the site of substitution. The renal excretion characteristics of 99mTc-MAGAG-DA are superior to those of 99mTc-MAG3 and the studied 99mTc-complexes in both animal species. In an attempt to improve the renal handling of 99mTc-MAG3 and to evaluate the effect of derivatization we have synthesized different derivatives of MAG3 in which one or more glycyl groups are replaced by other amino acids such as D- or L-alanine, D-serine, D-2-aminobutyric acid, D-valine or D-phenylglycine. Due to the presence of a chiral centre in the ligand core, exchange labelling of each of the MAG3 derivatives results in the formation of two diastereomeric technetium complexes. These isomers were separated by HPLC and evaluated in mice. Biodistribution in mice indicates that the efficiency of renal handling of the examined 99mTc-complexes is not only influenced by their lipophilicity but also to a great extent by their configuration. The renal excretion characteristics of isomer DA of 99mTc-MAGAG in mice are superior to those of all other studied 99mTc-complexes and also of the reference compound [131I]Hippuran. The isomers LB of several alanyl derivatives of 99mTc-MAG3 exhibit a pronounced renal retention in both mice and baboon. The results of the evaluation in a baboon confirm the superiority of 99mTc-MAGAG-DA over 99mTc-MAG3 and the other studied 99mTc-complexes.

Posterolateral bone grafting for nonunion of the tibia.

Sixty-two tibial diaphyseal nonunions in 60 patients were treated with a posterolateral bone graft over an 18-year period (1969-1987). The majority were complicated by severe soft tissue damage or segmental bone loss. Thirty-four had a deep infection. Primary healing was achieved in 92%. Three types of bone grafts have been used: from 1969 to 1978 either a whole iliac bone graft (10 tibiae) or a nonvascularized fibular graft (11 tibiae) was used. Since 1978 small iliac cancellous bone chips (41 remaining tibiae) were applied to the posterior surfaces of tibia and interosseous membrane. In three tibiae with major bone defects, cancellous allografts were added to the autogenous bone. The use of cortico-cancellous bone chips resulted in a shorter healing time, compared to a nonvascularized fibular graft or a massive corticocancellous bone block.

In situ posterolateral fusion for spondylolisthesis.

In this series spondylolisthesis was treated operatively in children and adolescents who had a displacement greater than 50% even if they were asymptomatic. In youngsters with less than 50% displacement and in adults, operative stabilization was performed if the displacement was progressive or if there were persistent symptoms unresponsive to conservative treatment that interfered with the patient's normal activities. The operation consisted of a posterolateral fusion in situ. Usually a laminectomy was not performed unless there were signs of severe neural compression. No reduction of the spondylolisthesis was attempted. We reviewed 38 cases treated operatively with a mean follow-up of 7 years. Twenty patients were younger than 20 years at the time of operation and 10 of these had greater than 50% displacement. The results were good to excellent in 90% (18 patients). In the adult group (18 cases) the results were less favorable, but still good to excellent in 72% (13 patients). In the adult group pseudarthrosis frequently occurred at the L4-L5 level. There were no neurologic complications postoperatively. Fusion in situ for spondylolisthesis is a safe operation giving satisfactory results.

The syndrome of Parsonage and Turner. Discussion of clinical features with a review of 8 cases.

A clinical analysis of 8 patients with brachial plexus neuropathy is presented. The disease may involve the upper, the lower, or the entire plexus. There is a higher incidence in men than in women. The syndrome is not uncommon but is frequently diagnosed incorrectly. The fairly typical pattern of symptoms and signs includes sudden onset with severe pain along one side of the shoulder girdle, followed in a few hours or days by atrophic paralysis of muscles over the affected shoulder. The disorder is occasionally bilateral. The paresis persists for months or even years. The overall prognosis is excellent despite the severity and extent of the lesion. The etiology is unknown, but decreased physical resistance is a predisposing factor.

Bilateral fracture-dislocation of the sacrum.

The authors describe a semiconservative approach for bilateral fracture-dislocation of the sacrum, an extremely rare injury. Traction is advocated; it seems to lead to a good functional result after 20 years. Other authors either propose internal fixation or benign neglect, also with a good outcome. Every case must be approached on an individual base.

Interlocking nail: a practical aiming device for distal screw insertion.

The fixation of segmental, distal third and comminuted femoral and tibial fractures by means of an interlocking nail is widely accepted now. A simple self-built target device allows easy placement of the distal transverse screws.

Synthesis and biological characteristics of the four stereoisomers of 99mTc-N,N'-bis-(mercaptoacetyl)-2,3-diaminopropanoate.

To study the differences in biological behaviour between the four stereoisomers of 99mTc-CO2-DADS we synthesized both the L- and D-isomer of N,N'-bis-(benzoylmercaptoacetyl)-2,3-diaminopropanoic acid ethyl ester. The N2S2 ligands were labelled with 99mTc by the dithionite reduction method in alkaline medium to hydrolyze the ester function. Each isomer yielded two diastereomeric 99mTc-complexes, that were separated by RP-HPLC to finally obtain the four isomers of 99mTc-CO2-DADS. The biodistribution of the isomers was determined in mice and a baboon. The study in mice indicates that only the LB-isomer is responsible for the high liver uptake reported for (DL)-99mTc-CO2-DADS-B (Fritzberg et al. J. Nucl. Med. 23, 592-598, 1982). The rate of renal extraction and hepatobiliary excretion of the three other isomers is comparable to that of [131I]o-I-hippurate. Baboon renograms for the LA- and DA-isomers are similar to that of [123I]o-I-hippurate. The renogram of the DB-isomer resembles more the 99mTc-DTPA renogram, whereas the LB-isomer exhibits a 99mTc-DMSA-like renal build-up. It appears that minor configurational changes can drastically alter the renal handling of these bisamide bisthiol 99mTc-tracer agents.

Soft tissue involvement, mediastinal pseudotumor, and venous thrombosis in pustulotic arthro-osteitis. A study of eight new cases.

A syndrome of hyperostosis of the thoracic wall, nonspecific signs of inflammatory disease, and palmar and plantar pustulosis is described in eight patients (Table 1). Seven had intersternocostoclavicular ossification, and one had chronic recurrent multifocal osteomyelitis. This complex of findings has been called "pustulotic arthro-osteitis". This report emphasizes the periosseous soft tissue inflammation and the unexplained subclavian and mediastinal vein thrombosis seen in two patients. Inflammatory periosseous and mediastinal lesions were seen on plain films in all eight patients and on computed tomographic (CT) scans in seven. Radiographs of the spine showed a spondyloarthropathy in three patients. This was characterized by ossification of the vertebral ligaments and sclerosis of the vertebral bodies. Awareness of the radiologic features of pustulotic arthro-osteitis is important because the clinical, biochemical and pathologic findings are often nonspecific and misleading.