The role of the epiphyseal and metaphyseal circulations on longitudinal growth in the dog: an experimental study

An experimental model using the immature canine proximal fibular epiphysis was developed to isolate and investigate the effects of the epiphyseal and metaphyseal circulations on longitudinal growth. Experimental constructs studied the epiphyseal circulation, the epiphyseal and metaphyseal circulations, a devascularized growth plate, and a control group. Twenty-four limbs were studied by serial x-ray films and microangiographic and histologic analyses at time of death, 24 weeks after surgery. The data from this preliminary study show that both metaphyseal and epiphyseal circulations are necessary for predictable longitudinal growth.

The management of multiple fractures in one upper extremity: a case report

Multiple fractures involving the dominant proximal forearm and wrist in a 24-year-old woman were treated with a combination of internal and external fixation. The rigid skeletal fixation permitted rapid postoperative mobilization and a successful functional outcome.

The use of Y-shaped interposition vein grafts in multiple digit replantations

Y-shaped vein grafts that have been specifically selected from the venous anatomy on the dorsum of the foot have been used to bridge the arterial defects in multiple digit replantations. In this technique, the two outflow limbs of the Y-shaped vein graft are anastomosed to the distal digital arteries of two adjacent fingers before osteosynthesis. The inflow stem of the Y-shaped graft is then anastomosed to a common digital artery or to the superficial palmar arch to provide rapid and reliable restoration of arterial inflow simultaneously into two adjacent digits.

The management of delayed union and nonunion of the metacarpals and phalanges

Nonunion and delayed union of the tubular bones of the hand are uncommon occurrences, but are often associated with functional deficits. Twenty-five consecutive phalangeal and metacarpal nonunions and delayed unions in patients seen at the Massachusetts General Hospital were reviewed and classified by the criteria of Weber and Cech. Most of the patients treated had inadequate or improper primary Kirschner wire fixation. Secondary treatment depended upon the associated disability. In seven cases treatment was by bone excision, arthrodesis, or arthroplasty. No treatment was given in four cases. Fourteen patients had operations to gain skeletal union. Rigid skeletal fixation with plates or lag screws was used in seven cases and permitted rapid postoperative mobilization of soft tissue and joint.

Metastatic nontraumatic Clostridium septicum osteomyelitis

Nontraumatic clostridial infections are rare, but need to be diagnosed and treated early or high morbidity and mortality rates result. We believe that this is the first reported case of metastatic nontraumatic Clostridium septicum osteomyelitis. Early treatment with surgical debridement and parenteral antibiotics without hyperbaric oxygen was used. An associated occult rectal malignancy was discovered and treated.

Irreducible palmar dislocation of the proximal interphalangeal joint associated with an epiphyseal fracture of the middle phalanx

A palmar dislocation of the proximal interphalangeal joint that became irreducible because of a Salter-Harris type I fracture of the epiphysis of the middle phalanx is described. The anatomic mechanisms of irreducible palmar dislocations are discussed.

Intercondylar fractures of the humerus. An operative approach

In this paper we review a series of thirty-four intercondylar fractures of the distal end of the humerus that were treated by open reduction over a ten-year period. The fracture patterns were classified according to the system of Müller et al. and a strict rating scale incorporating subjective data, objective motion, and the functional status of the involved elbow was used for the results. At a mean follow-up of 5.8 years, thirteen results were rated as excellent; fourteen, as good; four, as fair; and three, as poor. Complications included postoperative neuritis in five patients; three non-unions; and refracture, heterotopic bone, and deep sepsis in one patient each.

Silicone synovitis of the wrist

Foreign body giant cell synovitis and focal bony destruction requiring secondary surgery developed in nine patients after carpal and radiocarpal arthroplasty with silicone rubber implants. Synovitis followed silicone rubber replacement of the lunate in four patients, the carpal scaphoid in two patients, and the trapezium in one patient, trapezial resurfacing hemiarthroplasty in one patient, and total wrist arthroplasty in one patient. All the removed implants were deformed. Some had changed in color from clear white at the time of insertion to yellow-white or deep yellow upon removal. Scanning electron microscopy of a silicone rubber implant of the lunate removed from one patient revealed extensive fibrillation in the capitate fossa. Light microscopy of the synovium revealed hyperplasia and hundreds of fragments of silicone particulate debris throughout the tissue adjacent to the implant. The silicone debris was surrounded by multinuclear foreign body giant cells in the eight patients from whom the synovium was studied. All patients required revision surgery. We believe that in the patients studied, synovitis represented a biologic reaction to the silicone fragments found scattered throughout the synovium for the following reasons: The synovitis found was not present before surgery (except in the patient with rheumatoid arthritis); the synovitis found was not associated with the condition for which replacement arthroplasty was performed (except in the patient with rheumatoid arthritis); synovitis subsided after implants were removed; and synovitis was noted histologically in areas of silicone debris and appeared directly related to silicone seeding. Fibrillation, fragmentation, and local seeding of silicone after carpal or radiocarpal arthroplasty appear related to gradual deformation of the implant, which was the result of repeated compressive loading and shearing. Clinically significant complications of rubber carpal or radiocarpal arthroplasty with silicone rubber implants may develop from silicone synovitis.

Vascular injuries and closed extremity fractures in children

The association of a major vascular injury with a closed extremity fracture in the pediatric patient is uncommon. The present study of seven such patients includes five fractures treated by open reduction and internal fixation (ORIF) prior to vascular reconstruction. Two were treated in skeletal traction without vascular reconstruction. Most vascular injuries were not diagnosed initially, consequently delaying repair. Early follow-up examination revealed the following complications: wound infections, below-knee amputation, deep vein thrombosis (DVT), and motor and sensory deficits. All of the fractures healed. Late follow-up examinations revealed two cases of overgrowth and one of limb undergrowth. Minor motor and sensory deficits were present, but overall function was good. Arteriography should be performed prior to surgical repair. Because of problems with growth disturbance that require long-term follow-up evaluation, all major vascular injuries should be repaired despite adequate collateral circulation to keep the limb viable. Prompt, accurate diagnosis followed by surgical repair will improve the long-term results.

Lower limb replantation. A report of nine cases

An analysis of nine replantations of completely amputated lower limbs is presented in this paper. Four cases were successful, including two at the level of the distal third of the tibia, one through the midfoot, and one at the proximal third of the tibia. The latter case involved the replantation of the shortened limb followed by a Syme's amputation of the foot to preserve a functional below-knee amputation level. In each successful case protective sensibility, bony union, and a stable stance and functional gait has been achieved, thereby eliminating a prosthetic requirement.

The association of septic thrombophlebitis with subperiosteal abscesses in children

An association of septic thrombophlebitis with acute osteomyelitis in four children is described. Each patient presented with physical findings consistent with thrombophlebitis. Venography, done in two, demonstrated significant acute thrombophlebitis, and another had an infected venous cutdown. A subperiosteal abscess was the predominant bony involvement found in all three patients who underwent surgical drainage. The initial radiographs were normal in each case. Bone scans showed diffuse increase in activity in the extremity, consistent with hyperemia, but no focal areas of increased uptake to suggest osteomyelitis. Computerized tomography, done in two patients, failed to reveal any bony abnormality, although subperiosteal abscesses were drained within 48 hours of each study. The existence of reverse collateral venous flow through the bone, associated with a rise in intramedullary pressure, may be responsible for these findings.

The effect of hypothermia and tissue perfusion on extended myocutaneous flap viability

The salutary effect of hypothermia and tissue perfusion on extending the ischemic tolerance of the canine latissimus dorsi myocutaneous flap was demonstrated in this experimental study. A total of 175 flaps from 89 adult mongrel dogs were elevated with one-half the flaps perfused with iced Collins renal preservation solution. With the exception of control flaps kept at ambient temperature, the remaining flaps were stored at 4 degrees C for periods ranging from 24 to 192 hours followed by transplantation into the groins of recipient dogs, with anastomosis of the thoracodorsal artery and vein in an end-to-side manner to the femoral artery and vein, respectively. The study was divided into two distinct sections. The acute phase involved the transplantation of 77 flaps into random recipient dogs, and following a 3-hour period of systemic perfusion, the flaps were removed, weighed, and sectioned for later histologic study. Progressive increase in flap weight was observed up to 96 hours of hypothermia with a sharp decline in weight at 120 hours of hypothermia. The increase in flap weight in the nonperfused flaps was significantly greater than the previously perfused flaps. Histologically, at 120 hours of hypothermia, loss of vascular integrity was noted, suggestive of a no-reflow phenomenon. In the second, or extended-flap, study, 98 flaps were transplanted into the groins of the original donor animal and allowed to remain in situ for a 2-week period. The flaps were then carefully observed for viability, removed, and sectioned for histologic study. Hypothermic support of up to 96 hours extended viability in both perfused and nonperfused flaps, although beyond this hypothermic period viability was seen only in previously perfused flaps. The clinical implications of this study include hypothermic perfusion of a major-extremity amputation prior to replantation or the temporary storage of a free myocutaneous flap.

Vascularized autogenous whole joint transfer in the hand--a clinical study

Nine vascularized autogenous whole joint transfers were employed in the reconstruction of traumatized joints of six male patients ages 6 to 38 years. The proximal interphalangeal joint was involved in four patients, the thumb metacarpophalangeal (MP) joint in two, and the small finger MP joint in one. In five patients, the donor joint came from the foot, and in one patient an MP joint was transferred from a digit that had sustained a more distal amputation. The mean follow-up was 24 months (range 13 to 38). Bony union as well as full radiographic preservation of the articular space has occurred in each case. Four joints were transferred with an open epiphysis and three demonstrated longitudinal growth and an intact epiphyseal plate. The mean range of active motion was 22 degrees/55 degrees. We believe the early results demonstrate the feasibility of this method of joint reconstruction in the young patient.

Salvage replantation of lower limb amputations

Three cases are reported in which the microsurgical salvage of parts of traumatic lower extremity amputations associated with degloved proximal skin loss provided sturdy, sensate skin and soft-tissue coverage and thereby preserved functional below-knee amputation levels. In two instances, a free innervated filletted flap was constructed from the foot of the amputated limb, and in the third case, the amputated lower leg was shortened, successfully replanted, and followed later by elective amputation of a foot at the Syme level. At a mean follow-up of 2 years, all three patients are ambulating well in below-knee prostheses.

Reconstruction of severe transmetacarpal mutilating hand injuries by combined second and third toe transfer

This paper reports on nine instances of combined second and third toe-to-hand transfers in eight patients for severe transmetacarpal mutilating hand injuries. In four cases, the transfer included an innervated flap from the fibular side of the great toe to provide sensibility to a previously constructed osteoplastic thumb. Prehensile function was significantly improved by providing chuck or tripod pinch as well as improved pulp-to-pulp and lateral pinch. At a mean follow-up of 20.3 months, there was only one failure.