Light microscopy techniques for the demonstration of silicone gel

Because of the difficulty in identifying silicone gel in histologic and cytologic specimens by means of conventional light microscopy, we investigated alternative light microscopy techniques, as well as specimen staining and preparation. Specimens from six periprosthetic capsules, one silicone granuloma specimen, and one synovial biopsy specimen obtained from women with silicone breast implants were cut at 4-, 10-, 20-, and 30-microns sections, stained with a variety of common stains, and correlated with electron probe microanalysis. In addition, a commercial silicone gel and silicone gel extracted from a previously implanted silicone breast prosthesis were smeared and examined unstained or stained with Papanicolaou and Diff Quik. Silicone was noted to be refractile, nonpolarizable, and nonstainable. Thicker sections prevented silicone "dropout" during processing and increased the contrast between stained tissue and unstained silicone (negative staining). The relative ease of silicone identification was greatly increased with non-Koehler, phase contrast, and darkfield microscopy. Staining the mounting media of hematoxylin-eosin-stained sections with a nonparticulate commercial ink allowed enhanced negative staining detection of silicone gel.

Synovectomy of the ankle for hemophilic arthropathy

The results of five patients who had hemophilia and a history of recurrent hemarthrosis and hypertrophic synovitis and who had been managed with a synovectomy of the ankle were studied at an average age of nine years (range, four years and seven months to nineteen years). Compared with the complications encountered after synovectomy of the knee or the elbow, the rehabilitation process after synovectomy of the ankle was relatively easy, even for the three youngest children in this series. The average duration of follow-up was five years (range, one to nine years). By the latest follow-up examination, the range of motion of the ankle had increased an average of 10 degrees (range, -5 to 15 degrees). The rate of hemarthrosis episodes requiring transfusion was reduced from an average of 3.4 per month (range, 0.3 to 5.0 per month) for the six months before the synovectomy to 0.1 per month (range, zero to 0.2 per month) for the twelve months before the latest follow-up examination.

Etiology of late-onset tibia vara: is varus alignment a prerequisite?

One widely held theory on the pathogenesis of adolescent late-onset tibia vara is that obesity coupled with mild preexisting varus alignment produces forces sufficient to retard growth in the medial portion of the proximal tibial physis and initiates the development of the condition. Two cases are presented in which neutral mechanical alignment was clearly documented in an extremity that subsequently developed adolescent late-onset tibia vara within 19 months. We conclude that in at least some cases, preexisting varus alignment is not a prerequisite for the development of adolescent late-onset tibia vara.

Synovial metaplasia of a periprosthetic breast capsule

A 48-year-old woman presented for reconstruction mammoplasty 5 years after undergoing a mastectomy for breast carcinoma. She underwent tissue expansion, with subsequent placement of a permanent silicone implant, removal of the permanent implant because of asymmetry, and further tissue expansion for another attempt at permanent silicone implant placement. The periprosthetic breast capsule surrounding the initial permanent implant consisted of a lining intima, subintima, and fibrous capsule consistent with synovium on light microscopy, immunohistochemical studies, transmission electron microscopy, and scanning electron microscopy. Silicone was localized intracellularly within the lining cells and extracellularly within the fibrous capsule by electron probe microanalysis. We believe that this case represents synovial metaplasia of a periprosthetic breast capsule that was most likely induced by repeated manipulation and silicon exposure from silicone gel leakage and the prosthetic Silastic shell.

Genu varum and genu valgum in children

Genu varum and genu valgum are often normal developmental changes in knee alignment that occur in a young child. Measuring the child's height and understanding normal development is the key to determining which children need further evaluation for a possible skeletal or metabolic bone dysplasia.

Acrosyndactyly with epidermoid inclusion cysts: evidence for the extrinsic theory

A case of acrosyndactyly was treated with routine syndactyly release and full-thickness skin grafts. Two epidermoid inclusion cysts were found within the syndactylyzed index and middle fingers. This association is discussed along with the mechanism that best explains this unusual occurrence.

One-stage release of congenital circumferential constriction bands

A one-stage release of circumferential congenital constriction bands was performed in four extremities (three patients). No wound problems occurred, even when there had been marked swelling of the extremity distal to the band. The one-stage release facilitated postoperative care, and there was no need for additional periods of anesthesia or for additional operations, which are necessary when this problem is treated with a release performed in two or three stages.

Endoscopic treatment of reflux: migration of Teflon to the lungs and brain

We set out to determine experimentally whether particles of polytetrafluoroethylene migrate to the lungs and brain when relatively small volumes of Teflon paste are injected into the bladder in the manner used to correct reflux. Numerous particles of polytetrafluoroethylene were recovered from these organs within 2 weeks of injection. Those in the brain measured up to 15 microns in diameter, indicating that the pulmonary bed is an inefficient filter of particles gaining access to the venous circulation. Although clinically no adverse neurological effects have hitherto been reported, this study suggests that following the 'sting' procedure, some particles may lodge in the brain where they can block the cerebral microcirculation. We believe these findings represent a contraindication to the use of Teflon paste in children.

Transfer versus lengthening of the posterior tibial tendon in Duchenne's muscular dystrophy

Transfer of the posterior tibialis tendon to the dorsum of the foot was compared with lengthening of this tendon in 15 patients with Duchenne's muscular dystrophy. Patients undergoing tendon transfer (N = 9) had a longer operating time and two perioperative complications, but retained plantigrade posture of their feet even after walking ceased. By contrast, lengthening of the posterior tibialis tendon (N = 6) was associated with a recurrent equinovarus foot deformity that frequently interfered with shoe wear. Although transfer of the posterior tibialis is out of phase and technically more demanding, the unique prolongation of posterior tibialis strength in Duchenne's muscular dystrophy makes this operation a better option for these patients.

Displaced supracondylar humeral fractures in children. A comparison of results and costs in patients treated by skeletal traction versus percutaneous pinning

Clinical outcome and treatment cost were compared in 65 children treated by either percutaneous pinning or skeletal traction for displaced supracondylar humeral fractures. Clinical outcome was evaluated by loss of elbow motion and change in carrying angle. Results of treatment were basically equivalent in the two groups and were satisfactory in 90% or more. To determine treatment cost, the authors analyzed factors that vary according to the type of therapy. Cost of treatment was lowest in those who had percutaneous pinning and subsequent pin removal in the office. Compared to this group, the cost of treatment increased by 23% in those who had percutaneous pinning and removal of the pins as a surgical procedure, by 117% in those treated by traction with the olecranon pin inserted in the emergency room, and by 142% in those treated by traction with the olecranon pin inserted in the operating room.

An improved cryo-jet freezing method

A new cryo-jet freezing apparatus is described that is easy to use and gives good results using a propane-butene mixture (3:1). Our use of the freezer in the study of mouse spinal cord explant cultures is discussed. At the tissue surface, the quality of tissue preservation from freezing, followed by freeze substitution, rivals that of conventional electron microscopic methods. Certain intracellular structures are better visualized using our methods. There is no evidence of the tissue being distorted by the cryogen jet when the freezer is operated correctly. A new freeze substitution device is also discussed.

Adolescent tibia vara: alternatives for operative treatment

We reviewed the cases of fifteen obese patients (twenty-one extremities) who had had adolescent tibia vara and had been followed for at least two years. Of the nine patients (eleven extremities) who had been initially managed with lateral tibial hemiepiphyseodesis, eight (ten extremities) were skeletally mature at the time of the review (mean duration of follow-up, five years). The mechanical alignment was judged to be excellent in three of these ten extremities, fair in three, and poor in four. Excellent mechanical alignment was defined as a value within the reported normal range of 5 degrees of varus to 2 degrees of valgus. A poor result was defined as alignment that was more than 5 degrees outside the normal range. After secondary operative procedures, three of the extremities for which the result had been poor and one for which it had been fair had excellent alignment. Five of the nine patients had bilateral involvement. Two of them were managed with bilateral tibial hemiepiphyseodesis; two, with contralateral proximal tibial osteotomy; and one had a mild deformity on the contralateral side that was not treated. Six extremities in six patients (two of whom had a contralateral hemiepiphyseodesis) were managed primarily with proximal tibial osteotomy and were evaluated an average of seven years postoperatively. Two additional patients were managed with proximal tibial osteotomy because of residual varus deformity after the hemiepiphyseodesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid progression of hip subluxation in cerebral palsy after selective posterior rhizotomy

Rapid progression of hip subluxation was noted in the year after selective dorsal rhizotomy in seven hips (six patients). The hips that subluxed progressed from a lateral extrusion index averaging 25% preoperatively as compared with 50% after rhizotomy. Although preexistent hip dysplasia was a predisposing factor, hips with an intermediate degree of preoperative lateral extrusion (12-25%) had variable results. Ongoing and more frequent evaluation of hip stability is necessary after dorsal rhizotomy.

Vertebral Candida infections. A case report and review of the literature

Vertebral Candida infection in a 57-year-old woman became symptomatic three months following Candida septicemia associated with a central venous catheter. The infection was successfully treated with amphotericin B and ketoconazole. Review of the literature revealed 29 cases of Candida infection with vertebral involvement. Intravenous drug abuse and central venous catheters were identified as predisposing factors in 13 cases. An average delay from Candida septicemia until the time the patient sought treatment was 3.3 months. Antifungal agents generally resulted in resolution of the infection.

Osteomyelitis of the patella in children

The early diagnosis of osteomyelitis of the patella in children can be difficult due to the rarity of this infection and to the vagaries of presentation which may be either acute with systemic signs or insidious with mild local signs. We present four cases of patellar osteomyelitis to illustrate the spectrum of this disorder. There should be a high index of suspicion with persistent pain and swelling above the knee, septic prepatellar bursitis, and septic knees that do not respond to conventional management. Management parallels treatment of osteomyelitis of other bones.

Musculoskeletal problems in association with cloacal exstrophy

The records of all thirteen patients for whom a diagnosis of cloacal exstrophy had been recorded in our hospitals were analyzed for evidence of musculoskeletal problems. All thirteen patients had spina bifida, four had congenital scoliosis, two had congenital kyphosis, and three had non-congenital scoliosis. All had a lipomeningocele, and eleven had paralysis of the lower extremities. Hydrocephalus and its associated problems were not found, but tethered-cord syndrome was diagnosed in eleven patients. Persistent diastasis of the symphysis pubis was found in all patients. Abduction and external rotation of the hips were more than normal. Mild dysplasia was seen in six of the twenty-six hips. Deformities of the foot were common, and twelve feet had been operated on for correction. Recurrent equinovarus deformity of the foot was associated with tethered-cord syndrome in two patients.

Effect of race and gender on neurological level in myelomeningocele

The association of race and gender with different neurological levels of myelomeningocele was studied in 251 patients. Over-all, the white to black ratio was 3.6 and the male to female ratio was 0.86. However, the proportions of whites and females were significantly increased in thoracic-level patients (white to black ratio 13.6, male to female ratio 0.43), whereas the lumbar-level patients had sex and white to black ratios equivalent to the area population. This supports the concept that thoracic-level myelomeningocele has a different pathogenesis from lumbar-level.

Variability in radiographic measurement of bowleg deformity in children

The tibial metaphyseal-diaphyseal (MD) and tibial-femoral (TF) angles were measured on the radiographs of 33 knees in young children (aged 12-36 months) with bowleg deformity. Four observers of differing experience measured the films in a blinded fashion to determine the intraobserver and interobserver variability of these measurements. The clinical implications of these variabilities are described. Very little instruction and experience is necessary to make these measurements correctly and precisely. Measurement of the MD angle was superior to measurement of the TF angle. Contrary to published opinion, rotation can have a small but potentially significant effect on the measured MD angle.

Evaluation of magnetic resonance imaging in Legg-Perthes disease: a prospective, blinded study

Twenty-two patients (24 hips) with Legg-Perthes disease received 49 magnetic resonance (MRI) scans. The scans and corresponding radiographs were independently evaluated in a blinded fashion to assess the capabilities of, and indications for, MRI in Legg-Perthes disease. Early in the disease process, MRI often more clearly delineated the extent and location of areas of involvement than did plain radiographs. In one patient, MRI failed to indicate necrosis early in the course of the disease, but it was detected on plain radiographs. MRI can also be used to give a rough estimate of sphericity, which in some phases of the disease process is better than plain radiographs. For serially following the disease process through the natural healing course, plain radiographs were as good or better than MRI and considerably less costly.

Orthopaedic procedures and prognosis in hemophilic patients who are seropositive for human immunodeficiency virus

Thirty patients who had hemophilia and were seropositive for the human immunodeficiency virus were evaluated. The preoperative CD4 lymphocyte count was decreased to an average of 336 x 10(9) per liter (range, 27 to 708 x 10(9) per liter). After twenty-six orthopaedic operations in patients who had no previous bacterial infection, a nosocomial infection (cellulitis in the forearm, at the site of an intravenous catheter) developed in only one patient, but five patients had an abnormal postoperative fever that was not accompanied by the expected increase in the white blood-cell count. The preoperative CD4 lymphocyte count was significantly reduced in the patients who had an abnormal elevation in body temperature (p less than 0.004). The functional result or outcome after operation was similar to that in hemophilic patients treated before 1982. Subsequent progression of infection with the human immunodeficiency virus, as determined by the CD4 lymphocyte count and the Walter Reed classification system, occurred in most patients. Acquired immunodeficiency syndrome was diagnosed in six patients. A more rapid progression to acquired immunodeficiency syndrome was seen in the patients who had a lower CD4 lymphocyte count preoperatively. Preoperative evaluation of the CD4 lymphocyte count and the response to intradermal skin-test antigens in patients who are at risk for infection postoperatively provides additional information concerning immunological competence. With these data, the possible risk of infection in patients who are seropositive for the human immunodeficiency virus can be estimated more accurately.