Postosteotomy healing in Pyle's disease (familial metaphyseal dysplasia). A case report.

Pyle's disease is rare skeletal dysplasia in which a defect in metaphyseal remodeling leads to grossly widened metaphyses of long bones. Genu valgum, one of the few clinical findings in this disease, may warrant surgical intervention. Postoperative healing is documented only in Pyle's original patient. A case is presented in which bilateral osteotomies were performed through the proximal tibia for progressive genu valgum. The osteotomies healed within 12 weeks when treatment was performed with standard techniques. This information will allow osteotomies to be performed with confidence.

Quantitative analysis of cancellous bone graft available from the greater trochanter.

To quantify the amount of cancellous bone graft available from the greater trochanteric region, 20 paired iliac crest-proximal femur specimens were harvested and compared in 10 adult pelvises. A 1.3 x 1.3-cm cortical window was made in the lateral aspect of the proximal femur 2 cm distal from the tip of the greater trochanter. Cancellous bone evacuation was performed by curettage. The extent of harvest was mechanically limited by the medial wall of the trochanter and by curette impingement on the margins of the cortical window. The graft was quantitated after maximal digital compression in a 10-ml syringe and compared with cancellous graft obtained from the paired anterior iliac crest. The average compressed volume of cancellous bone harvested from the greater trochanter was 6.5 ml (range, 4.2-9.6 ml). The average iliac crest cancellous bone volume was 6.0 ml (range, 2.7-8.8 ml). Differences in graft volume between the anterior iliac crest and the trochanter were not statistically significant. The resulting defect in the proximal femur remained isolated to the trochanteric region. In this study, we demonstrate that cancellous bone is available from the greater trochanteric region in an amount similar to that available from the anterior iliac crest. We also show that it is obtainable in a reproducible manner. Our clinical experience of over 100 cases has demonstrated acceptable morbidity associated with this technique. The greater trochanteric region may be used as a secondary source of autogenous cancellous bone graft when specific procedures demand more bone graft than available from the iliac crest alone, or in patients who have had previous iliac crest graft harvest.

Clinically occult presentation of comminuted intertrochanteric hip fractures.

Hip fractures in awake patients are rarely subtle in their clinical presentation. We report two cases of occult, comminuted, intertrochanteric hip fractures that occurred in awake, elderly patients who were brought to the emergency department for evaluation of other medical conditions. Neither patient complained of hip pain, and both were transported to the ED without spinal immobilization. Physical examination revealed no sign of hip fracture. Patient 1 was scheduled for admission and just prior to transfer out of the ED developed hip pain. Patient 2 was admitted for workup of possible transient ischemic attack and approximately 2.5 hours after admission complained of hip pain. Radiographs of both patients revealed comminuted intertrochanteric hip fractures. In an elderly, nonambulatory patient who may have fallen prior to evaluation, routine radiographs of the pelvis and hip should be performed followed by plain tomography, computed tomography, bone scan, or magnetic resonance imaging as indicated to rule out occult hip fracture. Even comminuted intertrochanteric hip fractures can present in an occult fashion; therefore, a high index of suspicion must be maintained for these injuries.