The use of preoperative computed tomography scanning in total hip arthroplasty

Computed tomography (CT) scanning is a useful tool in many areas of orthopedics. This prospective study reviews the authors' experience with CT scans in 73 patients studied prior to total hip arthroplasty. The CT scan is valuable in the primary total hip arthroplasty if the radiograph suggests medial, posterior, or superior acetabular wall defects. In some instances, bone grafting or other special procedures are required for the reconstruction of these defects. In the present study, preoperative CT identified an abnormality in 18 cases with deficient acetabular walls, while plain radiographs identified only six of these difficulties. Although important information for planning revision total hip arthroplasties was noted in this series, CT scans are indicated primarily in instances of suspected acetabular wall defects.

Revision total hip replacement without trochanteric osteotomy

Revision total hip replacement has traditionally required a trochanteric osteotomy for successful cement removal and component reinsertion. In this study the authors have concluded that in most instances the revision total hip replacement procedure can be successfully performed without trochanteric osteotomy. The advantages are underscored by the high percentage of trochanteric complications with trochanteric osteotomy for revision total hip replacement and the ease of rehabilitation without trochanteric osteotomy. Also, improved functional results without trochanteric osteotomy were noted. The specific indications for the procedure included revision total hip replacement with ununited prior trochanteric osteotomy, revision total hip replacement with femoral shaft fractures, and revision total hip replacement with stem fractures requiring only acetabular revision. The contraindications to the procedure are fibrous union or ununited trochanteric osteotomy from prior total hip replacement, severe acetabular protrusion of the acetabular component, advanced myositis ossificans, ankylosis of the hip, and advanced proximal femoral osteoporosis. The operating room records, x-rays, and outpatient records of 63 total hip revisions in 52 patients were reviewed. There was a minimum 2-year follow up with a range from two years to seven years. The patients were divided into two groups, comparing 21 trochanteric osteotomized revisions to 44 with trochanteric sparing techniques. Both groups were analyzed for age, type of implant, intraoperative perforation of femur, intraoperative femoral shaft fractures, intraoperative cortical window, component malpositioning extraneous cement, intraoperative blood loss, operating time, postoperative leg length inequality, persistent abductor weakness, average first day of ambulation, wound infection, dislocation, nonunion of the trochanter, and postoperative pain. In the nonosteotomized group, there was a 21% decreased blood loss, a 14% decrease in persistent abductor weakness, a 14% decrease in subluxation and dislocation, a 30% decrease operating time and a 50% reduction in intraoperative femoral perforation. In the osteotomized group there were six cases of fibrous union of the greater trochanter, two cases requiring removal of broken wires for trochanteric bursitis. A detailed surgical technique and representative cases are presented. In carefully selected cases, revision total hip replacement is optimally performed without trochanteric osteotomy. Postoperative trochanteric problems of nonunion, broken wires, bursitis, and abductor weakness can effectively be eliminated by avoiding trochanteric osteotomy.(ABSTRACT TRUNCATED AT 400 WORDS)

"Idiopathic" scoliosis associated with congenital upper-limb deficiency

Sixty patients with congenital upper-limb deficiency were evaluated for scoliosis in 1972. Twenty-one patients had scoliosis of 5 degrees or more and 15 had scoliosis of 10 degrees or more. Fifteen of these patients had long-term follow-up periods. Thirteen patients had idiopathic scoliosis. Idiopathic scoliosis associated with congenital upper-limb deficiency could be divided into three groups, and the progression of scoliosis was predictable within each group. All but one of these patients had a relatively benign course and did not require treatment. Double curves with rotation progressed throughout the growth period. Double curves with Grade 0 rotation tended not to be progressive. Single curves did not have rotation deformity and resolved spontaneously or remained stable. Magnitude of limb deficiency did not correlate with the curve magnitude, progression, or pattern. Muscle imbalance did not appear implicated as a cause for the scoliosis in these patients. Young age at discovery of the curve did not correlate with progression of the curve.

Muscle biopsy: proper surgical technique

Muscle biopsy is often incorrectly performed despite the fact that it is a relatively simple procedure. A consistently reproducible surgical technique in 93 open vastus lateralis muscle biopsies implemented in conjunction with neuromuscular and malignant hyperthermia research demonstrated 14 cases of malignant hyperthermia and a variety of forms of neuromuscular pathology. No wound complications or disabilities have resulted from this procedure. The procedure includes careful selection of biopsy site, regional anesthesia, atraumatic dissection, and immediate processing of the biopsy sample. A new muscle biopsy clamp is described. The authors recommend the vastus lateralis for the biopsy site unless another area of involvement is specifically indicated. Careful attention to technical details is required for optimal results.

Low-velocity gunshot wounds in police officers

One hundred forty-five Philadelphia police officers were injured as a result of gunfire during the period from January 1971 to February 1983. Arrests and arrest attempts were the most common causes of these injuries; on- and off-duty accidents were the second most common causes. Twenty fatalities occurred among the 145 officers. Specific medical and surgical management of gunshot wounds depended largely on the location of the wound and the extent of the damage. Analyses of the location of the wounds in this study revealed that many could have been alleviated through the use of body armor, such as bullet-proof vests and lightweight helmets. Of the treatment records of 100 patients completed for evaluation, average hospitalization time was ten days, time without duty averaged 143 days, and limited duty averaged 70 days. Twenty-two persons received permanent and partial disabilities related either partially or wholly to their wounds. Fourteen individuals expressed anxiety about returning to work as police officers, and two received disability retirements for emotional instability. An officer who is aware of the probability of injury while performing a specific task can decide whether to wear an armored helmet or bullet-proof vest at the appropriate time. In the treatment of low-velocity gunfire injury, the physician could use the guidelines reviewed for specific treatment of the injury and thus anticipate the length of time or probability of the individual returning to work. Early recognition of these factors could help to avoid psychologic trauma.

A comparison of CT scanning and myelography in the diagnosis of lumbar disc herniation

Computerized tomographic (CT) scanning of the fourth and fifth lumbar disc spaces with the GE CT/T8800 scanner followed by metrizamide myelography was obtained for 134 consecutive patients with suspected lumbar disc disease. There was an overall concordance rate of 85% between CT scanning and myelography. In those 52 patients treated by surgery, concordance between the CT and the myelogram was similar at 86.5%. Myelography and surgical findings were in agreement in 94.2% of cases, while CT findings and surgical finding agreed in 92.3% of cases. The authors' data indicate that the CT scan is as accurate as myelography in the diagnosis of lumbar disc disease. When the CT scan interpretation is supported by clinical findings, the myelogram may be eliminated in the preoperative patient. Myelography may be reserved for equivocal cases.

The effects of epidural injection of local anesthetics and corticosteroids on patients with lumbosciatic pain

Although epidural cortisone injections are commonly used for treatment of lumbosciatic pain, insufficient critical analysis of the end result can be found in the literature. The present study is a retrospective critical analysis of 367 patients with leg pain who were engaged for a minimum of two weeks or an average of two months in multifaceted conservative management without relief of pain. Injections of 10 cm3 of 0.5% bupivacaine and 100 mg of methylprednisolone were given to inpatients treated by the same anesthesiologist. The average follow-up period was 21.4 months (range, 6-36 months). Results were analyzed according to duration of pain and history of prior lumbar spine surgery. The most favorable results (approaching 70% offd-excellent) were observed in patients with subacute radicular leg pain (of less than three months' duration) and chronic leg pain (of greater than three months' duration) with no prior surgery. Negative myelograms and electromyograms (EMGs), in the absence of reflex or motor deficits on physical examination, also pointed toward optimal results. Those patients with chronic pain who had had prior lumbar spine surgery had the least satisfactory results.

Thermally induced bone necrosis in rabbits. Relation to implant failure in humans

The exposure of bone to high temperatures has become quite common, especially with the increasing use of polymethylmethacrylate (PMMA) bone cement. With particular regard to total hip arthroplasty, many authors have commented on the temperature problem induced by the curing PMMA cement mass. Polymerization temperatures at the bone-cement interface have been measured and range between 40 degrees and 110 degrees, depending on the thickness of the cement line. Thermal bone damage is implicated as a significant cause of early loosening of implanted joint prostheses. The authors designed a fluid probe to deliver heated isotonic fluid directly over exposed cortical bone on a rabbit's proximal tibia. Scald temperatures ranged from 45 degrees-90 degrees for a standard exposure time of one minute. Bone tissue samples taken at intervals of one, two, and three weeks postoperatively were used to establish the thermal-damage threshold for living bone and assess regeneration potential. Controls were included to observe the reaction of bone to the surgical procedure. Bone necrosis was consistently seen in histologic sections at scald temperatures greater than or equal to 70 degrees. Although an inflammatory reaction replaced by a fibrous tissue scar was seen at the site of surgically damaged periosteum, no control animals showed evidence of either bone or marrow necrosis. These results led the authors to suggest that joint replacement systems in human bone, using PMMA bone cement, be designed to limit intraoperative temperature maximums to a level less than 70 degrees. By preventing excessive bone necrosis at the bone-cement interface, early loosening and subsequent implant failure may be significantly reduced.

Surgical management of lumbar disc disease

The normal and pathologic anatomy and biochemistry of lumbar disc disease have been discussed. The use of various diagnostic modalities to support the clinical diagnosis has been assessed. Details of a conservative care program are outlined. A discussion of surgical indications and techniques for laminectomy, reoperative laminectomy, and posterolateral spinal fusion is also presented. The use of chymopapain is briefly described in anticipation of its imminent usage.

Treatment of osseous cryptococcosis report of a case and review of the literature

Isolated osseous cryptococcosis is rare. We present a case of lytic femoral lesion due to Cryptococcus neoformans in a healthy young man. Such a lesion should prompt a search for more widespread, disseminated disease. Treatment consists of surgical curettage and intravenous amphotericin B or a combination of amphotericin B and flucytosine. Key indexing words: cryptococcosis, osteomyelitis, fungus, amphotericin B, flucytosine.

Central acetabular fracture-dislocation secondary to an epileptic seizure in a chronic renal patient

An unusual mechanism of injury for a central acetabular fracture-dislocation is reported in a patient with chronic renal insufficiency. The combination of renal osteodystrophy and an epileptic seizure resulted in such an injury as a complication of renal dialysis. Skeletal traction and a prolonged period of non-weight bearing produced a satisfactory result.

Patellar tendon rupture with underlying systemic disease

Two patients with patellar tendon rupture and underlying systemic disease are described. One had systemic lupus erythematosus and the other had chronic renal failure and secondary hyperparathyroidism. There have been 13 other cases of patellar tendon rupture in patients with systemic disease reported in the literature and they are reviewed. Patellar tendon rupture has occurred spontaneously in more than one-half of the cases and has been associated with rupture of the contralateral extensor tendon mechanism in 87%. Although patellar tendon rupture almost always occurs at the tendinous insertion, on a rare occasion (as in one case described in this report), the tear may involve the main substance of the tendon, which is the part of the tendon with the greatest tensile strength. The relation between systemic disease and patellar tendon rupture is discussed and the clinical and radiographic findings are described.

Fracture toughness concept applied to methyl methacrylate

Polymethyl methacrylate bone cement is tested at the Institute of Fracture and Solid Mechanics Laboratory, Lehigh University. Standard tensile coupon and compact tension specimens are molded under varying conditons of temperature and pressure. Test results are obtained for the strength and toughness of bone cement involved in total hip replacement operations.

The temperature problem at the bone-acrylic cement interface of the total hip replacement

Loosening of total joint replacements may be caused in part by thermal necrosis of bone in contact with the high temperature of the polymerizing PMMA acrylic cement. This study reports a method to reduce the temperature of the bone-cement interface below the temperature at which bone results in definite necrosis. By precooling the acetubular component to --84 degrees before insertion into the cement, the temperature during polymerization at a simulated bone-cement interface can be reduced from 70 degrees to 49 degrees with an increase of only approximately 51/2 minutes in the cement setting time.

The Guillain-Barre syndrome in children. Orthopedic management and patterns of recovery

Eleven cases of Guillain-Barre Syndrome in children between 1955 and 1973 demonstrate clinical course and residual permanent motor deficits. The rate of recovery from muscle paralysis and the long-term permanent muscle loss, and the resultant paralytic deficits may require treatment: tendon transfers, opponensplasties, spinal fusions, and Lambrinudi operations. The late permanent motor paralysis and residual joint deformities secondary to GBS in children has a higher incidence and severity than in adults, and an intensive rehabilitation program in imperative. Frequent, extended follow-up, and muscle testing records are absolutely essential in children.