The migration of a Harrington rod after cervical fusion.

A patient was treated for an anterior dislocation of C4 on C5 with an open reduction and Harrington rod hook fixation. The compression rod dislodged and migrated through the foramen magnum into the cerebellum 4 years later. This case represents an unusual complication of Harrington rod instrumentation in the cervical spine.

Nerve root recovery in complete injuries of the cervical spine.

Thirty-six patients with complete quadriplegia were reviewed. Twenty-two underwent surgery, and 14 did not. There were 11 burst fractures and 3 extension fracture-dislocations, which were treated with anterior decompression and rigid plate fixation. There were 22 flexion injuries that were treated with posterior stabilization using Kirschner-wire tension band fixation, Harrington compression hooks, or Halifax laminar hooks. The non-operative group was treated with skeletal traction with skull tongs for 6-12 weeks followed by the application of a hard collar or halo vest for 3 months. Of the 22 patients who underwent surgery, 32% descended one level and 18% two levels. In the nonoperative group, only one patient descended one level. It is concluded that the heretofore pessimistic outlook regarding complete quadriplegia is unwarranted and that a more aggressive approach may result in a better functional outcome.

Acute ascending myelopathy of the spine.

Ascending myelopathy of the cervical spine is a clinical condition in which ascending paralysis manifests itself from 24 hours to 4 weeks after the initial injury. One hundred thirty-four patients with spinal cord injury were reviewed; 80 underwent surgery and 54 were treated conservatively. Ten of the 54 patients who did not have surgery ascended one to four levels, whereas only 4 of the 80 patients who underwent surgery ascended to similar levels. Myelography demonstrated diffuse swelling of the cord that extended approximately two segments above and below the injured vertebrae. Magnetic resonance imaging showed intrathecal hemorrhage within the first 2 weeks followed by cord atrophy within 4 weeks after the initial trauma. Thorough decompression of the cord with rigid internal fixation markedly reduced the incidence of this complication.

Reconstruction of malunited fractures of the lateral malleolus.

The cases of twenty-six patients who had a reconstructive surgical procedure for treatment of a malunion of a displaced fracture of the fibula were evaluated. In these patients, who had pain, swelling of the ankle, and stiffness at an average of six years after the injury, the malunions were classified radiographically as either occult (eighteen patients) or overt (eight patients). An occult malunion was one in which the talus remained in its normal position, but the lateral malleolus showed residual displacement, characterized by external rotation and shortening. In an overt malunion, there were similar changes in the lateral malleolus, but the talus was displaced. All of the patients were treated by osteotomy of the lateral malleolus to correct the external rotation and shortening, to reduce the lateral subluxation of the anterior aspect of the tibiofibular joint, and to restore the stability of the talus. At an average follow-up of seven years (range, six months to eleven years), twenty of the twenty-six patients were able to resume the preinjury level of activity; three had improvement in the ability to walk and in the level of functional activity, although they still had intermittent pain; and three had not benefited from the procedure.

Occult malunion of ankle fractures--a cause of disability in the athlete.

Occult malunion of the ankle is a condition in which the talus appears to be situated in its normal position on standard radiographs. The lateral malleolus, however, is incompletely reduced. This causes a subluxation of the distal tibiofibular joint and some degree of talar instability. The malunion of the lateral malleolus is best visualized on lateral radiographs or tomograms. This condition can be corrected by osteotomizing the lateral malleolus and restoring the integrity of the distal tibiofibular joint by pulling the lateral malleolus distally and internally rotating it.

Pyogenic sacroiliitis. An absolute indication for computerized tomographic scanning.

Pyogenic sacroiliitis (PSI) resulted from direct injection of a foreign substance, pumice, in a 32-year-old woman and was complicated by iliopsoas abscess. The symptoms of PSI are unspecific, and similar complaints may accompany such conditions as herniated disc and arthritis. Results of physical examination may be misleading, especially if movements that stress the sacroiliac joint are omitted. Early roentgenograms are normal and rarely aid in the diagnosis. Scintiscanning with gallium and technetium may indicate an inflammatory pelvic focus. These methods lack specificity, however, and may underestimate the extent of disease. The computerized tomographic (CT) scan was effective in detecting interosseous gas with an associated soft tissue abscess. It also proved invaluable in precisely delineating the location and extent of the lesion in and around the sacroiliac joint, facilitating use of the most expeditious surgical approach. Through follow-up CT studies the course and end results of therapy can be objectively determined.

Treatment of ankle malunion.

Surgery of the ankle has reached the stage where reconstruction of malunions are not only possible but advisable. It is becoming more evident that if done early, and if done before the onset of arthritic changes, good results can be obtained. Certainly it is far more preferable to restore a malunited ankle to a functional level than to allow the patient to continue to experience pain and to wait until degenerative arthritis requires that an arthrodesis be performed.

Matrix antigens in allografts. II. The cell-mediated response.

The cell-mediated response of link proteins (LP) and proteoglycan monomer (PG), the matrix antigens of articular cartilage, was investigated in the late rejections of joint allografts in dogs. Cell-mediated immunity was present as determined by the Macrophage Inhibition Test and by skin sensitivity, which was present at 26 and 52 weeks after allografting. The Migration Inhibition was 70% at 12 weeks, and 50% at 26 and 52 weeks after allografting. Skin sensitivity was present after these intervals. The synovium was hypercellular, had the appearance of a pannus, and invaded and destroyed the graft.

Matrix antigens in allografts. The humoral response.

The roles of matrix antigens, link proteins (LP) and proteoglycan monomer (PG) were investigated with regard to the late rejection of joint allografts. Antisera to these antigens were produced in the rabbit. With the use of immunofluorescent techniques, these antigens can be detected in host synovium as early as six weeks after transplantation. At about 12 weeks, antibody reaction against LP and PG was detected in the recipient synovium and circulation. After transplantation there is apparently a slow release of antigen from the cartilage matrix that is concentrated within the synoviun. An immune response occurs in the tissue which subsequently becomes transformed into a pannus and ultimately destroys the allograft. Whether the humoral response observed is primarily responsible for allograft rejection has not been determined. LP and PG could evoke a cytotoxic response that is more significant. Histocompatibility antigens could be primarily responsible for allograft rejection and the humoral response to LP and PG may be a secondary phenomenon.

Acid hydrolase activity following allografting.

The synovium of dogs receiving an osteochondral allograft of the distal femur has similar characteristics to a rheumatoid synovium. Since it is generally believed that the cartilage destruction in rheumatoid arthritis is related to the release of hydrolases from lysosomes, the following study was performed to determine whether a similar phenomenon is responsible for the destruction of transplanted articular cartilage. Host synovium revealed an almost threefold increase in acid phosphatase activity at 26 and 52 weeks after transplantation when compared to controls. Electron microscopy studies showed a marked increase in the number of lysosomes seen in the type A synovial cells at 26 weeks, degradation of the cartilage matrix, and the presence of enzyme reaction product when treated for cytochemical demonstration of acid phosphatase activity. It is concluded that the host synovium destroys the allograft by the release of lysosomal enzymes.

Isolated fracture of the lateral malleolus.

Isolated fractures of the lateral malleolus are stable only if no other ligaments are torn. These fractures are unstable if accompanied by a tear of the deltoid or anterior tibiofibular ligament and it may be necessary to demonstrate the resulting talar instability by stress radiographs. Stable fractures are best treated by the application of a short-leg walking cast. In unstable fractures an attempt should be made to anatomically reduce the lateral malleolus by closed means followed by the application of a long-leg cast. Should subsequent loss of position occur or should it not be possible to obtain an anatomical reduction, then open reduction and internal fixation is indicated.

Acute bilateral anterior dislocation of the shoulders.

In 3 cases of simultaneous bilateral anterior dislocation of the shoulders, considering the forces which predispose to anterior dislocations, it is postulated that in each case forced abduction and external rotation or abduction with hyperextension causes these injuries to occur.

The preservation of articular cartilage.

Slivers of articular cartilage were stored in Ham's medium, plasma, polyvinyl pyrrolidone, and dimethyl sulphoxide at 0, -20, 4, and 38C. Survival was monitored by potassium determinations and autoradiography using S-35 and by matrix staining. Survival of 48 days was obtained in Ham's medium at 4C.

Destruction of joint homografts. An experimental study.

The host synovium undergoes a striking transformation at about 26 weeks after joint homografting. Histologically the synovium invaded and destroyed the graft with which it came in contact, becoming markedly hypercellular; the infiltrate consisted mainly of plasma cells and lymphocytes. The synovium at this stage closely resembled a rheumatoid pannus. The cartilage in contact with this invasive synovium lost its staining qualities, failed to take up S-35, and was gradually destroyed. The mechanism causing this transformation remains unclear. It is postulated that these changes could be due to an inflammatory or immune response.

The key role of the lateral malleolus in displaced fractures of the ankle.

The reason why late degenerative arthritis developed in some patients who had sustained displaced bimalleolar fractures of the ankle was investigated. The roentgenograms indicated that incomplete reduction of the lateral malleolus and a residual talar tilt were present. When bimalleolar fractures were created in cadavera the talus could be anatomically repositioned only when the lateral malleolus was accurately reduced. Fifty-three patients with bimalleolar fractures were treated by anatomically fixing the lateral malleolus with a four-hole plate. There was an anatomical reduction of the talus and medial malleolus in each instance and there were no late cases of degenerative arthritis when these patients were followed for from six months to nine years. We concluded that the lateral malleolus is the key to the anatomical reduction of bimalleolar fractures, because the displacement of the talus faithfully followed that of the lateral malleolus.

Recent advances in the treatment of pathological fractures.

Pathological fractures present challenging and difficult management problems. Conservative treatment frequently results in non-union, while open reduction and internal fixation usually involves prolonged immobilization and bed rest with attendant medical complications. The use of methylmethacrylate as an adjunct to conventional forms of internal fixation represents a recent advance in the management of unstable, pathological fractures. The hospital stay can be markedly shortened and the patient's functional capacity increased relatively early in the postoperative period. This paper reports the results of this approach to therapy in a series of over 75 patients, and outlines indications and timing of this procedure before pathological fractures occur in instances where early diagnosis of bone malignancy has been made.

The augmentive use of methyl methacrylate in the management of pathologic fractures.

Methyl methacrylate is a useful adjunct to obtain secure internal fixation in the treatment of comminuted pathologic fractures. This method was used in 73 patients with 81 pathologic fractures of whom only four failed to regain function in the extremity which was operated upon. While it is probable that methyl methacrylate may have an adverse effect on fracture healing, the fixation achieved when applied to only one surface appears adequate and was observed to last for as long as nine years. The use of methyl methacrylate to augment internal fixation of pathologic fractures offers the patient a better chance to return to normal activities than any of the methods that are in use to date.

The effect of methylmethacrylate on fracture healing.

Fractures were created in the femur of dogs by dividing the midshaft with an airdriven saw. Immobilization was achieved with a four-hole compression plate. No methylmethacrylate supplementation was used in the control groups. In the three experimental groups methylmethacrylate was added to the internal fixation by placing it on the endosteal, periosteal, and both surfaces of the bone. Healing of the fractures uniformly failed to occur when methylmethacrylate was apposed to both periosteal and endosteal regions. Histologic, fluorescent, and autoradiographic studies indicated that the bone surface in contact with methylmethacrylate was necrotic and did not incorporate tetracycline or Ca-45. New bone occurred only on the surface which was not in contact with methylmethacrylate.

Limp in childhood.

A method is presented to assist the physician in diagnosing the cause of a limp in a child. This is based on how diseases alter locomotion. The normal gait can be affected in any one of five ways: shortened extremity, contracture, loss of supporting structures, pain, and paralysis. Each of these pathological states produces a characteristic limp which can be observed and recorded by noting the movements of the pelvis and the trunk, and the position of the joints of the lower extremities. Once the examiner has determined how the gait is affected, it becomes less difficult to determine the causative condition, based on the history, physical examination, and ancillary studies which would be ordered.