Coracoid process fracture combined with acromioclavicular dislocation and coracoclavicular ligament rupture. A case report and review of the literature

A coracoid process fracture associated with acromioclavicular joint dislocation and with rupturing of the coracoclavicular ligaments of an adult has been reported only once in the literature. This report adds another unusual case to the literature to reemphasize the importance of recognizing this unusual lesion. Two separate mechanisms--direct trauma to the shoulder girdle and sudden pull on the coracoid process by the conjoined tendons of short head biceps and coracobrachialis muscles--appear to be responsible for this unusual triple lesion. Open reduction with coracoid screw and acromioclavicular fixation, combined with an All-dredge repair to replace the ruptured coracoclavicular ligaments, resulted in an excellent outcome.

Comparison of dynamic compression plating and reamed intramedullary nailing in the treatment of aseptic tibial shaft nonunions

Among 105 tibial shaft aseptic nonunions followed for a mean of 32 months, 30 were treated with dynamic compression plating and 75 were treated with either Küntscher or Grosse-Kempf interlocking intramedullary nailing. With the plating technique, the union rate was 90.0% (27/30), the period of time to union was 5.2 +/- 1.7 months, the complication rate was 16.7% (5/30), the infection rate was 13.3% (4/30), and the surgical time was 110 +/- 30 minutes. With the intramedullary nailing technique, the union rate was 93.3% (70/75), the period of time to union was 5.0 +/- 1.6 months, the complication rate was 17.3% (13/75), the infection rate was 13.3% (10/75), and the surgical time was 70 +/- 30 minutes. Thus, while the union rate was high with both techniques, the complication rate also was high, especially deep infection. However, the technique for nailing was simpler and required less surgical time than plating (p less than 0.001). With open reamed intramedullary nailing, a higher infection rate was noted in the cases initially treated with an external fixator than for cases in which other forms of treatment initially were used (p less than 0.05).

Acute septic arthritis of the hip in children--clinical analyses of 31 cases

This is a retrospective study of 31 cases of acute septic arthritis of the hip in children treated at Chang Gung Memorial Hospital from 1983 to 1989. The average follow-up period was 35 months. Among them, there were 18 males (58%) and 13 females (42%). None were involved bilaterally. Fifteen cases (48%) were below 5 years of age. All cases met the diagnostic criteria including bacteriological results, clinical and radiographic changes. Limited range of motion, fever, and tenderness were the most common symptoms and signs. More than half of the patients (52%) had a leukocyte count of over 15,000/cmm. The erythrocyte sedimentation rate was elevated in 30 cases (97%). Pathogens had been isolated from blood, arthrocentesis fluid, or surgical specimens in 26 cases (84%). Staphylococcus aureus was the most common causative organism (58%). Twenty-seven cases (87%) underwent emergency arthrotomy and debridement. Five (19%) of them received unsatisfactory results. A delay in definite treatment, very young infants, and the association with osteomyelitis of the adjacent bone were the important factors associated with poor prognosis. Four cases (13%) who received only medical treatment showed satisfactory results. Early diagnosis and significant response to antibiotics contributed to this favorable outcome.

Allograft transplantation in aggressive or malignant bone tumors

Twenty-three patients with aggressive benign or malignant bone tumors had segmental allograft replacements after resection of the tumors. The mean age of the patients was 30 years of age. The mean length of the allografts was 14 cm. The allografts consisted of intercalary allograft (5), allograft arthrodesis (12), and allograft-prosthetic composite (6). Intramedullary fixation with or without additional compression plate was used to osteosynthesize all the osteotomy sites with the exception of one in which a long nail plate was used. A supplement of autogeneic bone grafts at the allograft-host junction was performed in 18 patients. Seven patients received preoperative and postoperative chemotherapy for high grade sarcomas. At an average follow-up period of four years, 78% of the patients had excellent or good results. The union rate of the grafts was 86%. Supplement with autografts shortened the union time of the allograft from 15 to eight months. One patient had a tumor recurrence and one died of the disease. Other complications included one delayed union, two nonunions of the allograft, two late infections, and one neuropathy. Allograft transplantation is an acceptable method for tumor reconstruction. The adjuvant chemotherapy did not have significant adverse effects on its outcome. Complications that relate to allografting are common, but most of them are salvageable.

Segmental tibial shaft fractures treated with interlocking nailing

Thirty-eight segmental tibial shaft fractures were treated with closed Grosse-Kempf interlocking nails and retrospectively followed up for > or = 1 year (average 32 months). There was a 97% union rate and a 4.5 +/- 1.6 month union period. Knee as well as ankle range of motion was satisfactory. Significant complications included one aseptic nonunion (3%), which healed after the static locked nail was dynamized. We recommend that whenever possible, closed interlocking nailing should be used to treat closed or mild open (wound size < 1 cm) segmental tibial shaft fractures.

Simultaneous dislocation of the five carpometacarpal joints with concomitant fractures of the tuberosity of the trapezium and the hook of the hamate: case report

Multiple carpometacarpal dislocations, with fractures of the trapezium and hook of the hamate carpals are rare. We report an exceedingly rare constellation of these injuries. The routine use of a carpal tunnel view is advised to identify the associated avulsion fractures with multiple carpometacarpal dislocations. We found little on this subject in existing papers. It is important because painful nonunion of avulsion fractures and compressive ulnar or median neuropathy may be ignored and thus not receive suitable treatment.

Effect of dynamization of a static interlocking nail on fracture healing

A retrospective study was done of 22 patients with complex femoral (11) and tibial (11) shaft fractures treated with static interlocking nailing followed by dynamization, which was carried out on average 7.8 months later. The success rate was 54% with no significant difference between the healing of femoral and tibial fractures. The follow-up was at least 2 years. The interval from nailing to dynamization did not correlate with the success rate; the longest interval associated with successful healing was 20 months. The authors found that static interlocking nailing without dynamization can still produce a high union rate, and if there is sparse callus formation during the healing process, indicating low osteogenesis, dynamization will result in fracture union in only half the cases. To improve the union rate, cancellous bone grafting may be necessary.

Squamous cell carcinoma complicating tibial osteomyelitis treated with local wide excision and staged microvascular reconstruction

Squamous cell carcinoma is a complication of chronic tibial osteomyelitis treated with limb-preserving surgery. A 61-year-old man with 42-year history of chronic osteomyelitis of the left tibia was found to have malignant change. A curettage procedure was performed by a general surgeon. He then was referred to the osteomyelitis service; local wide excision was followed by staged microvascular latissimus dorsi muscle flap and fibular osteoseptocutaneous flap transfer. The patient remains well 36 months later with no clinical or radiologic evidence of local recurrence or distant metastasis. This kind of limb-sparing treatment is an excellent alternative treatment for malignancy.

Complicated open fractures of the distal tibia treated by secondary interlocking nailing

From January 1987 through December 1990, 28 consecutive distal tibial complicated open fractures in adults treated with primary external fixation and secondary closed Grosse-Kempf interlocking nails were prospectively studied and followed up for at least 1 year. All fractures were type IIIb open fractures and local soft-tissue coverage was performed at 3 to 5 days. The external fixation was maintained for an average of 22 days. The closed interlocking nails were inserted about 2 weeks after Hoffmann pins were removed. The results revealed a union rate of 85.7% (24 of 28) with a period to union of 5.8 +/- 1.4 months. Complications included 14.3% nonunion rate and a 7.2% deep infection rate, which were not difficult to treat. We conclude that secondary closed interlocking nailing is a simple and effective technique in treating distal tibial complicated open fractures.

Selection bias from differential residential mobility as an explanation for associations of wire codes with childhood cancer

Several studies of childhood cancer, especially leukemia, in residential areas have reported an association with wire configuration codes. These codes were suggested to be surrogates of electromagnetic field exposure. However, the selection criteria used in several of the studies caused the case and control populations to be non-comparable, especially with respect to residential mobility. Specifically, controls were required to be residentially stable but cases were not. Thus, an artificial association between residential mobility and cancer was created by the subject selection procedure. The present study of 5721 residences in Columbus, Ohio was conducted to learn if bias due to differences in residential mobility, rather than electromagnetic fields, could explain the reported association between wire configuration codes and childhood cancer. It was found that the proportion of homes classified as "high" wire code in the non-stable population was 31% greater than the corresponding proportion in the stable population. This finding shows that high wire codes are associated with homes in which the residents are mobile and low wire codes are associated with homes occupied by stable residents. Thus, as a consequence of this association between residential mobility and high wire codes, studies that created an artificial association between residential mobility and childhood cancer will also produce a false association between high wire codes and cancer.

Monteggia fractures in adults

From January 1978 to December 1989, 60 adult acute Monteggia fractures were treated and followed-up for at least one year (average 3 years 9 months). Ulnar fractures were treated with open reduction and internal fixation with a dynamic compression plate or a Rush pin, and 2 with minimal ulnar displacement were treated with closed reduction. Forty radial heads had a closed reduction, 6 required an open reduction with annular ligament repair or fascial reconstruction, and 14 were resected due to comminution. The results showed a 90% union rate with a 3.5 +/- 1.2 months union period. Functional evaluation revealed a 78% satisfactory rate. The unsatisfactory results were associated with severe soft tissue injury which restricted elbow range of motion, persistent posttraumatic neurological deficit of brachial plexus injury and subluxation or redislocation of the radial head. From theoretical and clinical considerations, the authors concluded that open reduction with rigid internal fixation of ulnar fracture and stable reduction of radial head should be the treatment of choice for Monteggia fractures.

Treatment of recurrent adamantinoma of the tibia by wide resection: report of three cases

Three cases of recurrent adamantinoma of the tibia were treated by wide resection and frozen allograft reconstruction. After an average follow-up period of 4.5 years (from 3.5 to 5.5 years), all allografts were found to have united to both ends of the host bone and none of the patients suffered further recurrence. According to Enneking's criteria for functional evaluation, two patients had excellent results and one had a good result. Therefore, it appears that amputation is not the only solution for recurrent adamantinoma of the long bone. In selected cases, wide resection and allograft replacement can achieve a satisfactory result.

Treatment of segmental femoral shaft fractures

In a prospective study, 35 segmental femoral shaft fractures were treated either with closed intramedullary nails (most were Grosse-Kempf interlocking nails) or an open method technique (most were open Küntscher nails with supplementary wires). The follow-up period was at least one year. There was an 82.9% (29/35) union rate and a union period of 6.1 +/- 1.9 months. Knee range of motion was on average 125 degrees. Although there was no statistical difference, the closed intramedullary nailing group showed superiority to the open method group. Complications were not particularly different from those in other type fractures, but could be managed better. Closed nailing technique can be improved with training and experience. Whenever possible, with adequate indications, closed intramedullary nailing is better than open treatment for segmental femoral shaft fractures.

Femoral shaft fractures associated with unstable pelvic fractures

From December 1986 to December 1989, 23 consecutive adult patients with femoral shaft fractures associated with unstable pelvic fractures were prospectively studied. The mortality rate was 8.7%. An anterior frame of an external fixator was sometimes inserted emergently in patients with multiple injuries to improve their bedside care. Early reamed femoral intramedullary nailing accompanying closed or open reduction with internal fixation, external fixation or both for unstable pelvic fractures was the favored treatment method. Twenty cases were followed for an average of 26 months. The union rate was high (95%) and the complication rate was low (5%). Hip and knee joint function was also satisfactory. Combined femoral shaft and unstable pelvic fractures are severe injuries and necessitate aggressive emergent management. With the techniques described, patients can achieve optimal outcome.

Femoral shaft fractures complicated by fracture-dislocations of the ipsilateral hip

A series of 16 consecutive adults with femoral shaft fractures complicated by fracture-dislocations of the ipsilateral hip joint was prospectively studied. There were 11 posterior dislocations and five central dislocations. The treatment consisted of early closed reduction of the dislocation with the assistance of an external fixator, delayed reamed intramedullary nailing of the femoral fracture, and conservative or surgical treatment of the hip joint according to the indications. The follow-up period was 2-8 years (median, 3.5 years). Although an 18.8% (3 of 16) complication rate was noted, the outcome was satisfactory for all 16 hip joints. When such complicated combined injuries are sustained, the technique described here is the most reasonable treatment.

Treatment for nonunion of the shaft of the humerus: comparison of plates and Seidel interlocking nails

From July 1986 to November 1989, fractures of the humeral shaft in 35 adults who had nonunion of the fracture were managed by plate fixation (19 patients) or antegrade nailing of the fracture fragments with the Seidel interlocking nail (16 patients) together with cancellous bone grafting. The follow-up period ranged from 12 to 52 months. Of the patients who had plate fixation, 89.5% had fracture union within 4.5 +/- 1.7 months; of the patients whose fracture was managed with the Seidel interlocking nail, 87.5% had fracture union within 4.4 +/- 1.8 months. The range of shoulder motion was improved with both techniques. Patients who had plate fixation had more complications than those whose fracture was managed by interlocking nailing (21% v. 12%). The authors prefer interlocking nailing because it is a relatively simpler technique, resulting in fewer complications. It may replace plating in the treatment of nonunion of humeral shaft fractures. However, rotatory instability with interlocking nailing cannot be disregarded, and if this is evident plate fixation should be done.

Brachial plexus injury with erect dislocation of the shoulder

Luxatio erecta, or inferior dislocation of the glenohumeral joint, is an extremely uncommon variety of shoulder dislocation. Several types of neurovascular injuries may be associated with luxatio erecta. Concomitant fracture of the coracoid, clavicle, acromion, greater tuberosity, and humeral head may also be noted. A case of luxatio erecta associated with a fracture of the greater tuberosity and transient mixed brachial plexus injuries is presented.

Management of infected tibial intramedullary nailing using an organized treatment protocol

Twenty cases of osteomyelitis, following intramedullary nailing of tibial shaft fractures, were managed with a prospective treatment protocol, comprising intramedullary reaming debridement, antibiotic-bead depot, external skeletal fixation, microvascular muscle flap and early cancellous bone grafting. The follow-up period ranged from 25 to 48 months (average, 34.3 months). Pseudomonas aeruginosa (37.5%) and Staphylococcus aureus (20.8%) were the organisms most commonly involved. There were eight united and 12 ununited fractures after reaming debridement surgery. Nineteen infections were initially arrested by one debridement. One infection was arrested by two Sequential debridements. All 12 ununited fractures were stabilized by Hoffmann unilateral external fixation until the fracture healed. The time spent in external fixation ranged from three to seven months (average, 5.2 months). Early cancellous bone grafting was successfully accomplished for nine ununited fractures with major debridement bone loss. The average union time of the nine fractures with bone grafting was 6.5 months (range, from six to eight months). We believe that this treatment protocol gives a predictable and rapid recovery. The complications were infection recurrence in two cases at the old tibial shaft fracture sites, minor Hoffmann pin tract infection in two cases and stiffness in two ankles and one knee.

Osteofibrous dysplasia (ossifying fibroma of long bones). A report of four cases and review of the literature

Osteofibrous dysplasia (ossifying fibroma of long bones) is a rare fibroosseous lesion. Only about 64 cases have been reported in the English literature. It is most commonly found in the tibia and fibula of a child ten years of age or younger. Of the four cases reported in this study, however, only one patient was younger than ten years of age. In two cases, the lesions were unusually located in the radius and ulna respectively. The other two cases had the usual tibial involvement. The last case had two recurrences after curettage before the patient was ten years of age. The other three patients who were treated after the age of 18 years had uneventful healing, one after wide resection and two after curettage. Extensive histologic examination and immunostaining for keratin were performed in all cases. No epithelioid cells were found. Because of a high recurrence rate after curettage, the treatment of this disease in a child should be conservative if the diagnosis is confirmed by biopsy. Only curettage with bone grafting is necessary for those patients older than 15 years of age with symptomatic lesions.

Management of infected tibial plate osteosynthesis using a staging system for infected fractures

Osteomyelitis following plate osteosynthesis of a tibial shaft fracture was managed in 23 patients through a staging system and prospective treatment protocol. The staging system, which is arranged in an upstaging disease progression and downstaging treatment protocol, is composed of the status of osseous continuity (Type I to II) and the dead space created by the debridement surgery (Classes A to D). The follow-up period ranged from 20 to 48 months (average, 31.5 months). Staphylococcus aureus (35.5%) and Pseudomonas aeruginosa (29%) were the most commonly involved organisms. Twenty-two infections were initially arrested by one debridement, and one infection was arrested by three sequential debridements. There were seven Stage IA, one Stage IB, seven Stage IIA, two Stage IIB, three Stage IIC, and three Stage IID fractures in this study. The average number of surgical procedures were 1, 2, 2.1, 4, 4.7 and 6, respectively. The difficulty of treatment increased with the severity of the disease. The average time to bone union for Stage IIA, IIB, IIC and IID fractures were 11, 9, 20.3 and 21.5 months, respectively. A tibial osseous defect longer than 4 cm is a major prognostic factor for prolonged disability time. Important complications were nonunion one, bone graft stress fractures (two), and recurrence (three).

Simultaneous bilateral femoral shaft fractures

Simultaneous bilateral femoral shaft fractures are unusual injuries caused by severe force and are usually associated with multiple injuries. There are few reports in the literature. From December 1986 to April 1989, there were 21 consecutive adult (greater than 16 years old) bilateral femoral shaft fracture cases treated at our hospital. The incidence was 2.0% (21/1,065). The associated multiple injuries (42 sites; 2.0 sites per case) markedly influenced the prognosis. There were two deaths, one bilateral above-knee amputation, and 15 cases followed for at least 1 year (average, 25 months). The individual fracture union rate was 80.0% (24/30) and the union period, 5.1 +/- 1.7 months. Complications (26.7%, 8/30) included nonunion, 20.0% (6/30); chronic osteomyelitis, 3.3% (1/30); and, limb shortening, 3.3% (1/30). All complications were in the open method treatment group: 40.0% (8/20) (p less than 0.05). We conclude that bilateral femoral shaft fractures indicate severe systemic and local injuries necessitating aggressive management, and the femoral shaft fracture itself should be treated with a closed nailing technique.

Necrotizing fasciitis of the extremities

Necrotizing fasciitis is a limb- and life-threatening soft-tissue infection. Eighteen patients with necrotizing fasciitis of the extremities were reviewed. These infections occurred most commonly after minor trauma. Associated chronic debilitating diseases were present in 13 patients. All but two infections were polymicrobial. The overall mortality rate was 33%. Death was caused by persistent wound sepsis in three and systemic septic complications in spite of apparent local infection control in three. At the admission physical examination the condition may resemble a benign, low-grade cellulitis. Three of four patients died because of a delay in surgical debridement for more than 24 hours after admission. Multiple radial debridements of the involved skin, fat, and fascia are essential to control progressive necrosis. Our results suggest that early diagnosis and prompt surgical debridement of necrotizing fasciitis are essential for survival.

Treatment of 84 cases of femoral nonunion

Eighty-four femoral nonunions were treated with Küntscher nailing, Grosse-Kempf locked nailing, plating, and Huckstep nailing, and were followed-up for a median of 34 months. Küntscher nailing and locked nailing were superior, with fewer complications, less operation time, and less blood loss. A Küntscher nail was preferred for the isthmic region when there was no shortening of the bone, and a locked nail was preferred above or below this region or when lengthening was indicated.

A simpler surgical technique to treat aseptic nonunion-associated femoral length discrepancy

In a prospective study from December 1986 to August 1989, 17 consecutive patients with femoral shortening due to aseptic nonunion of femoral shaft fractures were treated with limitedly open Gross-Kempf locking nailing with a lengthening procedure. Patients were followed up for at least 1 year (average 25 months). There was a 88.2% union rate with an average union period of 5.2 months. Average lengthening was 2.4 cm (1.0 approximately 3.0 cm), and average operation time 90 min (70 approximately 130 min). The blood loss was slight (average 200 ml). Complications (11.8%) were 5.9% implant failure and 5.9% nonunion which were not difficult to manage. No neurovascular complications were noted. We conclude that for 5 cm shortening or less in femoral aseptic nonunion, this treatment constitutes the simplest technique and can achieve a very satisfactory result.

Biomechanical analysis of the mechanism of interlocking nail failure

From December 1986 to May 1989, 412 patients with 274 femoral and 144 tibial fractures were treated with Grosse-Kempf interlocking nails at our hospital. 324 cases (78.6%) were followed-up for at least 1 year (average 23 months). There were 13 breakages in the locking nails in femora and none in tibiae. The recorded incidence of breakage in the femur is therefore 4.7% (13/274). The mechanisms of locking nail failure are stress concentration around screw hole and nail slot, nicking of the nail during drilling of the screw holes, too close proximity of the screw hole to the fracture, and larger loading over the proximal femur. The incidence of failure is 4.9% in the upper third, 1.9% in the mid-third, and 8.2% in the distal third (P greater than 0.05, chi 2 test). The site most at risk is the first screw hole of the distal third, especially if it is near the fracture site. Prevention of failure involves using a nail of larger diameter and sufficient length, improving the surgical drilling technique, and allowing only protected weight bearing. Management of nail breakage by insertion of a new implant and supplementary cancellous bone grafting can gain satisfactory results.

Posterior transpediculate Zielke instrumentation in spondylolisthesis

Between July 1987 and June 1989, 82 patients with spondylolisthesis (degenerative in 49, isthmic in 33) underwent Zielke posterior transpediculate instrumentation. One-level fusion was performed in 42 patients, two-level fusion in 32 patients, and three-level fusion in 8 patients. A supplemental allograft using frozen femoral heads was implanted in seven of the patients who underwent three-level fusion. The follow-up period ranged from 1.3 to 3 years (average, 1.7 years). Overall, 90.2% of the patients achieved solid fusion, and 85.4% had a good to excellent clinical result. Complications included nerve injury (one patient), rod breakage (four patients), nut loosening (11 patients), screw loosening (two patients), and screw breakage (three patients). The high incidence of instrumentation-related complications indicated that this technique must be further modified and refined.

A small effect of weight bearing in promoting fracture healing

We treated 66 consecutive type IV comminuted femoral shaft fractures with static Grosse-Kempf interlocking nails and followed them up for at least 1 year (median 27 months). Although the effect of weight bearing was completely lost, 60 fractures healed primarily without dynamization. We conclude that weight bearing contributes only an auxiliary role in promoting fracture healing, and that the most decisive role is adequate mechanical stability with sufficient nutrition.

Treatment of femoral supracondylar unstable comminuted fractures. Comparisons between plating and Grosse-Kempf interlocking nailing techniques

A prospective study was done of 66 consecutive unstable comminuted supracondylar femoral fractures in adults, fixed with either plates (28 cases) or Grosse-Kempf interlocking nails (38 cases). Patients were followed up for at least 1 year (average 44 months). Interlocking nails led to a higher union rate and more satisfactory functional results. Nevertheless, the first distal transverse screw hole took a potential risk of breakage due to stress concentration. The authors conclude that for a cooperative patient, a closed static interlocking nail with strict non-weight-bearing should be the treatment of choice, and for an uncooperative patient, a closed static interlocking nail should be supplemented with a cast brace to reduce the complication rate.

Treatment of open femoral and tibial shaft fractures preliminary report on external fixation and secondary intramedullary nailing

From January 1987 to May 1989, a total of 38 adult cases were treated with 15 femoral and 25 tibial shaft shifting procedures from external fixation to reamed intramedullary nailing and followed up for at least 1 year (average, 23 months) at the authors' institution. The indications for the shifting procedures included routine sequential femoral external fixation and failed tibial external fixation treatment such as loss of reduction, atrophic healing process and inability of patients to tolerate casting. The delay period for the shifting procedure was 5 days in the femur and 48 days in the tibia. The union rate for the femur was 93% (14/15), and the tibia, 96% (24/25). The union period after the shifting procedure was 4.8 +/- 1.7 months in the femur, and 5.2 +/- 1.8 months in the tibia. Range of motion of the knee and ankle were satisfactory. Deep infection was the most serious complication, and the tibia was involved more often than the femur (20% to 13%) (p greater than 0.05). The most favorable management of deep infection was local drainage till bony union. We conclude that a shifting operation can be considered as one of the alternative procedures for several femoral or tibial shaft open fractures after fixation with external fixation. Wound and pin tract care, a shorter period of external fixation, a longer delay period before nailing, and perioperative antibiotic use may significantly lessen the infection rate.

Distal femoral nonunion treated with interlocking nailing

From December 1986 to September 1989, 24 consecutive cases of distal femoral nonunion in adults were treated with Grosse-Kempf interlocking nailing and prospectively followed for an average of 32 months. The union rate was 91.7% (22/24) with a union period of 4.5 +/- 1.8 months. Complications occurred in two patients (8.3%), who suffered nonunion because of implant failure. A cast brace is very useful in promoting ambulation and reducing early overactivity. The potential for implant failure is a result of a concentration of stress over the nail hole, with the most stress occurring near the fracture site (p less than 0.05).

Femoral neck fractures. 121 cases treated by Knowles pinning

The femoral neck fracture remains one of the unsolved fractures. It is a fracture with a high incidence of nonunion and avascular necrosis. One hundred twenty-one mostly young adult patients with femoral neck fractures were treated by Knowles pins internal fixation. Patients were observed for an average of 32 months following surgery. Union occurred in all Garden Stage I and II undisplaced fractures, and the incidence of nonunion was 14% in Garden Stage III and IV displaced fractures. The incidence of avascular necrosis was 5.9% in undisplaced fractures and 34.5% in displaced fractures. There was no significant difference in avascular necrosis rates among age groups. Nonunion and avascular necrosis occurred mainly in displaced fractures. Knowles pinning offers the advantages of few technical failures, early weight bearing, high union rate, and low complication rate.

Chondrosarcoma of bone: a statistical analysis of prognostic factors

From 1980 to 1988, 30 cases of chondrosarcoma of the bone were treated surgically. Twenty-seven cases were followed from 6 months to 8.7 years (mean, 3.2 years). In all cases, a clinicopathological review was performed and the significance of prognostic factors were analyzed. The five-year survival of total patients was 88%. The survival was related to adequacy of treatment and histologic grade of the tumor. The five-year survival of adequately treated patients was 100%, but in inadequately treated patients it was 68%. At 8.7 years, 100% of the patients with grade-1 or grade-2 tumors survived, compared to 50% of the six-month survival rate in patients with the grade-3 tumors. None of the grade-1 or grade-2 chondrosarcomas metastasized, while 75% of grade-3 chondrosarcomas metastasized. The incidence of local recurrence was influenced by adequacy of treatment. At the final follow-up, the recurrence rate in the adequately treated group was 7%, while in the inadequately treated group it was 57%.

Ipsilateral femoral neck and shaft fractures. Retrospective study of 33 cases

Forty-two consecutive adult patients with a concomitant ipsilateral femoral neck and shaft fracture were treated. The neck fracture was initially missed in 7 patients. Surgery was delayed for a median of 7 days because of the patients' poor general conditions. Thirty-three patients were followed up for 2 (1-6) years. All 33 necks healed, with a union period of 3.3 +/- 1.7 months; and 28 shafts healed after 7.9 +/- 1.8 months. Thus, the femoral shaft determined the total union rate and union period. All the complications, (eight out of 33) occurred in the open procedure group. Our series reveals that ipsilateral femoral neck and shaft fractures have a relatively satisfactory outcome. Closed Küntscher's nailing or interlocking nailing with supplementary Knowles' pinning is the preferable technique.

Interlocking nailing of distal femoral fractures. 28 patients followed for 1-2 years

We treated 28 fractures of the distal femur with a Grosse-Kempf interlocking nail, and the patients were followed for at least 1 year. Five fractures did not unite, and the rest healed after 5 (3-7) months. Nail breakage was the most serious complication; and the more distal the fracture was, the more easily the nail broke. With the addition of a cast brace and protected weight bearing, a locked nail is a good type of fixation for distal femoral fractures down to 4 cm above the condyles.

Replication-defective missense mutations within the terminal protein and spacer/intron regions of the polymerase gene of human hepatitis B virus

We have analyzed 11 independent mutations located at various domains of the polymerase gene (pol) of human hepatitis B virus. Surprisingly, one of the two missense mutants within the spacer/intron region appears to be lethal. This result further defines the N-terminal limit of the reverse transcriptase domain. Alternatively, it suggests the potential existence of a novel domain with an unknown function. Two missense mutations within the terminal protein (TP) domain appear to be replication-defective as well, suggesting a functionally essential role of the TP domain in DNA replication.

Dedifferentiated chondrosarcoma arising from osteochondromatosis. A case report

Multiple hereditary osteochondromata has a higher incidence (5%-25%) of malignant change into chondrosarcoma than solitary osteochondroma (1%-2%); but only less than 10% of all chondrosarcomas may undergo dedifferentiated change into fibrosarcoma or malignant fibrous histiocytoma. We have a case presented here with osteochondromatosis who was found to have dedifferentiated chondrosarcoma arising from pelvic osteochondroma. Radical extra-compartmental resection was done and followed by chemotherapy and radiotherapy. Recurrence was found 3 months later. Early recognition of malignant change and adequate surgical resection with adjuvant therapy may prevent local recurrence and increase the survival rate.

Effect of long-term alcohol ingestion on the femoral head of rabbit

Twenty New Zealand rabbits were chosen for this study (5 for controls and 15 for the alcohol group). In the alcohol group, each rabbit was fed with rice wine (2 g/kg/day alcohol) for 1 year. Bone marrow pressure of the femoral basal neck, erythrocyte sedimentation rate (ESR), liver functions, uric acid, triglyceride, cholesterol, amylase, and blood alcohol level were measured at 0 day, 6 months and 1 year. Finally, the rabbits were sacrificed at the end of the study. The livers and femoral heads were examined for pathology. The bone volume and fat cell size of the femoral head were measured with a computerized "Bone Scanner". The results (1 year comparison) were a significantly higher level of cholesterol in the alcohol group (72 +/- 40 mg% vs 26 +/- 8 mg%, p less than 0.05) and greater bone marrow pressure (27.71 +/- 8.97 mmHg vs 18.20 +/- 4.09 mmHg, p less than 0.05), and no significant difference in triglyceride, uric acid and liver function, ESR, etc., when using Student's 2-tailed t-test. Liver changes (fatty liver) occurred in 3 animals in the alcohol group. The effect of alcohol on the trabecular bone volume was not significant (51.5 +/- 4.6 vol.% vs 50.0 +/- 5.2 vol.%), but the average fat cell size of the femoral head was significantly larger than that for normal controls (2,745 +/- 605 mu2 vs 2,185 +/- 458 mu2, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Molecular analysis of the p53 alleles in primary hepatocellular carcinomas and cell lines

We have examined p53 oncogene/anti-oncogene alleles in 10 different human hepatoma cell lines and 18 primary hepatocellular carcinomas. The p53 allele in these hepatoma cell lines appears to be a frequent target of mutation as demonstrated by Southern and Northern blotting, immunoprecipitation and Western blot analysis. In general, the steady state level of p53 specific RNA or protein in these hepatoma cell lines is higher than in normal liver. However, in three out of ten cell lines, normal-sized p53 mRNA cannot be detected. In contrast, the involvement of the p53 allele in primary hepatocellular carcinoma appears to be an exceedingly rare event. Steady state levels of p53 specific RNA in primary hepatomas are practically indistinguishable from those in normal adult liver. Using the polymerase chain reaction technique, we have amplified and subcloned exons 5, 6, 7 and 8 of p53 from 10 different hepatoma samples. DNA sequence analysis of these exon subclones reveals no apparent structural alterations. Finally, synthesis of p53 specific mRNA or protein in a HepG2 human hepatoblastoma cell line does not appear to be affected by gene expression and replication of human hepatitus B virus. Surprisingly, unlike many other kinds of human solid tumors, point mutations in p53 do not appear to be important in primary tumors of hepatocellular carcinomas.

Biomechanical analysis of the dynamic hip screw in the treatment of intertrochanteric fractures

A prospective study was performed in 148 elderly patients (over 60 years old) whose intertrochanteric fractures were caused by moderate trauma. The patients were treated with dynamic hip screws and followed up for at least 2 years (average 34 months). The lag screw was placed as the biomechanical analysis favored. Follow-up showed that the majority achieved good union and were without mechanical failure. The authors conclude that a lag screw should ideally be placed inferiorly toward the medial margin in the frontal plane and centrally in the sagittal plane. The length of the lag screw should be such as to extend from 1.0 cm beneath the subchondral bone to the lateral femoral cortex. At least four cortical screws (piercing the cortex at eight points) should be inserted on the distal femoral fragment.

Tibial fracture with or without fibular fracture--clinical studies

This report investigated 145 cases of closed tibial fractures treated with closed reduction and cast immobilization, and followed up at least for 2 years, from 1981 to 1984, at Chang Gung Memorial Hospital of Taiwan. The total delayed or nonunion rate was 28.3% (41 patients), and the healing period was 4.6 months on average (range, 3-6 months). Among them, the delayed or nonunion rate in the tibial fractures with fibular fracture group was 33.3% (35/105), but in the tibial fractures without fibular fracture group it was only 15% (6/40). The difference between the groups was statistically significant (P less than 0.05). The severity of soft tissue injury may be a very important prognostic factor for bone healing.

Post-traumatic fat embolism syndrome--a 10 year retrospective study in Chang Gung Memorial Hospital

Forty patients with post-traumatic fat embolism syndrome (FES) from January 1977 through December 1986 were retrospectively analyzed. Diagnosis was made according to the criteria modified by Guard. All 40 patients had at least two major criteria, namely change in consciousness and hypoxia. Twenty patients (50%) presented with full-blown clinical features. Prompt respiratory support with oxygen mask or nasal prongs was the first line of treatment. Forty per cent of patients responded well, whereas the others had to be advanced to endotracheal intubation and mechanical ventilation with positive end expiratory pressure. Steroids were given to 80% of patients and better results were achieved than in the group not treated with steroids. The mortality rate was low (2.5%) and only four patients suffered prolonged cerebral sequelae. The clinical course and prognosis cannot be predicted from the severity of the fracture.

Ulnar variance and Kienböck's disease. An investigation in Taiwan

The correlation between negative ulnar variance and the occurrence of Kienböck's disease was evaluated in Taiwan. Two groups of subjects were studied. The first group consisted of 1000 normal subjects and the second of 18 patients with Kienböck's disease. Student's t-test was used to evaluate the significance of the difference between this and other published series. The mean was 0.313 mm in Group 1 and -1.222 mm in Group 2. The percentage with significant negative ulnar variance (the distal ulnar was at least 2 mm shorter than the radius) was 6.0% in Group 1 and 55.6% in Group 2. The difference between the two groups was significant. The mean ulnar variance of normal subjects in Taiwan differed significantly from the variance in Swedes and American blacks but not American whites. In Chinese patients with Kienböck's disease, the ulnar variance was predominantly negative, and the distribution of ulnar variance was similar to that of Swedish or American white patients. This study confirmed the association between negative ulnar variance and the occurrence of Kienböck's disease. This supports Hultén's hypothesis that negative ulnar variance may predispose certain individuals to the occurrence of Kienböck's disease.

Transcriptional activation and repression by cellular DNA-binding protein C/EBP

A putative transcription factor, C/EBP, isolated from rat liver nuclei, has been shown to bind to at least two different sequence motifs: the CCAAT promoter domain and a core sequence [GTGG(T/A)(T/A)(T/A)G] common to many viral enhancers, including simian virus 40 and human hepatitis B virus. It has been proposed that C/EBP might function as a positive transcription factor by facilitating the communication between promoter and enhancer elements through its dual binding activities to DNA. Surprisingly, results from three different approaches suggest that C/EBP functions as a transcriptional repressor to hepatitis B virus and simian virus 40. Further investigation indicated that C/EBP can function as both a transcriptional activator and a repressor, depending on the reporter gene system.

Lower extremity compartmental syndrome following snake-bite envenomation--one case report

Acute compartmental syndrome develops when the intracompartmental pressure rises rapidly, even if only for a short duration. Loss of function and/or viability of the intracompartmental muscles may occur within a short period. Consequently early recognition and management are essential. We report a case where a young child with severe snake bite envenomation who and acute compartmental syndrome who had complete functional recovery following emergent fasciotomy and delayed primary closure.

[Adult femoral shaft fracture treated with an intramedullary nail]

Femoral shaft fractures often happen, and usually indicate only one part of the traumatic injuries sustained by the body. Preoperative evaluation and management may be life-saving. The favored treatment of fracture itself is now intramedullary nailing. There were 144 adult cases treated with intramedullary nails and followed up for at least two years at Chang Gung Memorial Hospital from July 1981 to June 1984. The results revealed a high union rate 96.5% (139/144): closed method 100% (34/34), open method 95% (105/110). Significant complications requiring repeated annoying surgical reintervention were rare, only 4% (6/144), due to deep infection or nonunion. Bone union period was about four months. Range of motion of knee was also satisfactory. This study suggests enough benefit of the delayed closed intramedullary nailing in the management of femoral shaft fractures.

In vitro propagation of human hepatitis B virus in a rat hepatoma cell line

A rat hepatoma cell line (Q7) of Morris hepatoma origin was transfected with a construct containing the tandem dimer genome of human hepatitis B virus (HBV) and the neomycin-resistant selection marker. The culture medium of several neomycin-resistant single-cell clones was found to accumulate high levels of secreted HBV surface antigen and core-related e antigen. HBV-specific replication intermediates, including relaxed circular and single-stranded DNA with a minus-strand polarity, could be found in both the intracellular fraction and the extracellular culture medium by the Southern blot procedure. One of these clones, designated Q7 HBV-21, was characterized in further detail. DNA polymerase activity was present in the virus particles produced by Q7 HBV-21 cells. Characteristic transcripts of HBV, including the 3.5-, 2.5-, and 2.1-kilobase mRNA as well as a core-gene-related transcript of 2.2 kilobases could be detected. Electron microscopic examination of the conditioned medium from Q7 HBV-21 cells identified 42-nm Dane-like particles as well as 22-nm subviral particles with a spherical or filamentous shape. This Q7 HBV-21 cell line has been maintained in the absence of neomycin for 1 year without losing the properties of HBV DNA replication and Dane-like particle production. Our results strongly suggest that the species barrier of HBV infection is at an early step of viral absorption onto or penetration into the target hepatocytes. This nonhuman system for HBV production in culture could be used to complement the human HepG2 system.

Treatment of femoral shaft fractures with the Hoffmann external fixator in prepuberty

Twenty-two children with femoral shaft fractures, between the age of 10 and 14 years, were treated with the Hoffmann external fixation apparatus from 1980 to 1985. This method of treatment is very simple. It requires less surgical exposure and allows earlier ambulation and easy nursing care. In addition, it makes patients comfortable in multiple trauma conditions. The average time to union and removal of fixators was 72 days (range, 44 to 80 days). There were no deep wound infections, nonunions, or rotationary deformities. On followup, all patients regained the range of motion of knee joints in 3 months without significant leg length discrepancy or radiographic evidence of growth disturbance. The device may serve as an alternative method for femoral shaft fractures in prepuberty, especially in areas of tropical climate.

Acute femoral neck fracture in children--preliminary report

Nineteen children, aged 3-15 years, with acute femoral neck fracture were treated. The follow-up period ranged from 2 years to 6 years, 9 months (avg. 54.8 +/- 14.5 months). The clinical and radiological assessments were carried out according to the assessment system of Ratliff. Undisplaced fractures and all intertrochanteric fractures were treated conservatively and displaced ones by reduction and multiple pinning. The outcomes reveal 14 (79%) with good results, 2 (10.5%), fair and 3 (15.8%), poor. Four hips (21%) developed avascular necrosis with 2 requiring secondary surgical procedures. Both of them also had leg length discrepancy. Another 3 hips (15.8%) developed coxa vara, one of them had mild leg length discrepancy.

Femoral shaft fracture treated with Hoffmann external skeletal fixator in young teens

External skeletal fixation has been proved to be an effective method in treating complex femoral shaft fracture in adult patients with multiple trauma, extensive soft tissue injury or vascular injury which need reconstructive procedures. This method has the advantages of less extensive surgical exposure, easy wound access, and early ambulation. Twenty-two cases of femoral shaft fracture, between the ages of 10 and 15, were treated with the Hoffmann external skeletal fixator in Chang Gung Memorial Hospital from 1981 to 1985. The average time for union and removal of fixator was 72 +/- 8 days (from 44 to 150 days). The average leg length discrepancy was 0.6 +/- 0.3 cm. There was no deep wound infection, nonunion, rotationary deformity in closed fracture. All patients regained their range of motion of knee within 3 months after removal of the Hoffmann apparatus. The advantages of simple technique, less extensive surgical exposure, early ambulation, easy nursing care, patient comfort and no significant complications make it a good alternative method for treatment of femoral shaft fracture in young teens.