Expression of human papillomavirus type 6 E1, E2, L1 and L2 open reading frames in Escherichia coli

Open reading frame (ORF) fragments (putative gene fragments) from human papillomavirus type 6b (HPV-6b) were inserted into the bacterial expression vector pHK413 to provide viral antigenic determinants. Approximately 86% of the entire L1 ORF, 82% of the E2 ORF, and 52% of the L2 ORF were expressed in Escherichia coli. The E1 ORF was cloned as two fragments. The constructions containing E1n (coding for the N-terminal region) and E1c (coding for the C-terminal region) expressed 27% and 16% of the E1 ORF, respectively. Protein encoded by the L1 ORF, but not that encoded by the L2 ORF, reacted with antibodies elicited by disrupted bovine papillomavirus. These reagents will be extremely useful in unravelling the HPV-6b replication cycle.

Achilles tendon rupture. Occurrence with a closed ankle fracture

A 61-year-old man, involved in an automobile accident, sustained a complete Achilles tendon rupture with an ipsilateral, closed slightly displaced medial malleolus ankle fracture. The tendon rupture was not diagnosed before operation but was recognized at the time of open reduction of the ankle. This rare combination of injuries was apparently secondary to hyperdorsiflexion of the foot. The tendon rupture would have been missed had surgical treatment not been required. Unrecognized tendon ruptures associated with closed ankle fractures may be a cause of residual ankle-foot weakness, pain, loss of motion, or a combination thereof.

Acetabular epiphysis-labrum entrapment following traumatic anterior dislocation of the hip in children

Traumatic anterior dislocations of the hip during childhood are rare injuries. Although a concentric reduction can usually be achieved with closed techniques, open reduction is occasionally required. We recently treated two children, 10 and 13 years of age, with nonconcentric closed reductions following traumatic anterior dislocation sustained 6 weeks and 6 months previously, respectively. Preoperative evaluation revealed intraarticular entrapment of the acetabular epiphysis and its contiguous labrum as the cause of the nonconcentric reduction. This was confirmed at surgery. Although displacement of the acetabular epiphysis has not been previously described, it is probably a common source for cartilaginous and osteocartilaginous fragments that have been recognized at open reduction following both traumatic anterior and posterior hip dislocations in children. Damage to this secondary center of ossification does not appear to affect adversely further growth and development of the acetabulum.

Late skeletal deformities following meningococcal sepsis and disseminated intravascular coagulation

Late skeletal deformities following meningococcemia associated with disseminated intravascular coagulation are rare. Two basic lesions have been described: epiphyseal avascular necrosis and epiphyseal-metaphyseal defects. These occur primarily in the lower extremities and result in angular deformity and leg length inequality. We recently encountered these lesions in a child 3 years following sepsis. The etiology appears to be acute vascular thrombosis of epiphyseal and metaphyseal vessels mediated through the generalized Shwartzman reaction. An increased incidence of these deformities may be anticipated as more children survive fulminant meningococcemia.

Segmental spinal instrumentation in idiopathic scoliosis. A preliminary report

Eighty-six patients with idiopathic scoliosis who underwent a posterior spinal fusion using sublaminar segmental spinal instrumentation were analyzed retrospectively. There were two operative groups: group 1, 66 patients who had Harrington rod instrumentation and segmental wiring, and group 2, 20 patients who had Luque rod instrumentation. The clinical and radiographic data of the two groups were similar except for the passage of more sublaminar wires and increased intraoperative blood loss in group 2. Twenty intraoperative or postoperative complications occurred in 19 patients (22%) including 14 neurologic complications. Three patients (3%) had major spinal cord injuries, while 11 patients (13%) had transient sensory changes. There was no significant difference in the incidence of neurologic complications between group 1 or group 2. The remaining intraoperative complications were due either to anesthesia, positioning during surgery, or technique (dural tear). Late complications occurred in two patients in group 1 only: one each with rod breakage and hook displacement. Only one patient (1%) has required additional surgery. Our results indicate that although segmental instrumentation can be beneficial in idiopathic scoliosis, the incidence of complications, primarily neurologic, will be higher than expected. The major reason appears to be surgeon inexperience with passage of sublaminar wires. As experience increases, the incidence of complications declines and becomes comparable with conventional Harrington rod instrumentation alone.

Comprehensive management of arthrogryposis multiplex congenita

Arthrogryposis multiplex congenita syndrome, characterized by multiple congenital joint contractures, is a manifestation of a neurogenic or myopathic disorder of unknown etiology. An accurate diagnosis is critical in management strategy. Muscle biopsy is usually the most important diagnostic procedure. Once the diagnosis is established, a team approach to comprehensive care is instituted, and the child is assisted in achieving maximum cognitive, physical, and social development. Physicians, nurse clinicians, therapists, social workers, and others constitute the team and work in coordination to develop an individual habilitation plan. The treatment plan is continually updated and modified as needed. Because the musculoskeletal deformities are generally the most prominent abnormality, the orthopedist usually has the major role in management. The orthopedist may serve as coordinator of the comprehensive care team and therefore must have a fundamental understanding of and global approach to management.

Atlantoaxial rotatory subluxation, congenital absence of the posterior arch of the atlas, and cerebral palsy: an unusual triad

Posttraumatic chronic atlantoaxial rotatory subluxation and congenital absence of the posterior arch of the atlas are rare upper cervical spine abnormalities. The present case is that of a 4-year-old girl who had these two spinal disorders as well as spastic cerebral palsy. The interrelationship, if any, between these three conditions is unclear but presented an unusual diagnostic triad. A posterior spinal fusion between the occiput and third cervical vertebra was performed because of concern for upper cervical spine instability. The patient was immobilized in a halo vest, and a solid fusion occurred within 3 months. Preoperatively the child had never walked independently, but postoperatively, while wearing the halo vest, she was able to walk without external support, thus raising the suspicion of previous spinal instability. Fifteen months postoperatively she remains spastic but has a stable, orthotic-free, independent gait.

Postoperative neurological deficits in segmental spinal instrumentation. A study using spinal cord monitoring

We retrospectively analyzed the postoperative neurological complications in 137 patients who underwent a posterior spine fusion for scoliosis and had concomitant somatosensory cortical evoked-potential spinal-cord monitoring. The patients were divided into three specific operative groups: group 1, forty-nine patients who had a Harrington rod with segmental wiring (segmental spinal instrumentation); group 2, twenty patients who had Luque segmental spinal instrumentation; and group 3, sixty-eight patients who had a Harrington rod without segmental spinal instrumentation. There were neurological complications in twelve (17 per cent) of the sixty-nine patients in groups 1 and 2. Three patients (4 per cent) had a major injury to the spinal cord and nine patients (13 per cent) had only transient sensory changes. No difference was apparent between group 1 and group 2 in the degree of operative correction of curves or in the incidence of neurological complications. The one neurological complication (1.5 per cent) that occurred in the sixty-eight patients in group 3 was a Brown-Séquard syndrome. The factors related to increased risk for spinal cord injury in groups 1 and 2 included: (1) the passage of sublaminar wires in the thoracic and thoracolumbar spine, (2) intraoperative correction exceeding the preoperative bending correction, and (3) the surgeon's lack of adequate experience with the technique. With spinal cord monitoring we were able to predict the impending major neurological deficits, but the transient (sensory) changes that may be associated with segmental wiring were less reliably predicted.

Legg-Calvé-Perthes disease. The prognostic significance of the subchondral fracture and a two-group classification of the femoral head involvement

From previous experimental investigations of a model of Legg-Calvé-Perthes disease in young pigs, it was speculated that the early radiographic phenomenon of the subchondral crescentic-shaped radiolucent line is a pathological fracture and, furthermore, that this fracture initiates the stage of resorption. Being painful, the fracture also heralds the clinical onset of the disease. From these laboratory investigations, plus a preliminary radiographic investigation in children, it has been observed that only that portion of the epiphysis underlying the subchondral fracture is resorbed. The radiographic investigation of 1,057 children (1,264 involved hips) with Legg-Calvé-Perthes disease from four institutions included 376 hips in which the diagnosis had been made early and the subchondral fracture was detectable. In all of these hips the extent of the subchondral fracture correlated precisely with the subsequent extent of maximum resorption. Consequently, in the early stage of Legg-Calvé-Perthes disease the extent of the subchondral fracture is of prognostic significance in predicting the eventual extent of involvement of the femoral head. We propose a simple and practical two-group classification of the extent of involvement of the femoral head: Group A (less than half of the head) and Group B (more than half of the head). The classification can be applied in the early stage of the disease when the subchondral fracture is detectable as well as throughout the ensuing resorptive stage.

Late-onset tibia vara: a comparative analysis

We reviewed the clinical and radiographic characteristics and response to treatment of 11 children (16 knees) with idiopathic late-onset tibia vara (adolescent Blount's disease) followed for an average of 5.7 years (range, 3-10 years). The clinical characteristics were very consistent: black race; 2:1 male predominance; normal height; marked obesity; knee pain as the primary presenting complaint; and slowly progressive genu varum deformity that averaged 19 degrees (range, 10-45 degrees). Radiographically, the epiphyses were wedge shaped owing to medial flattening, the physes were irregular in thickness, and there was minimal, if any increased prominence of the proximal medial metaphysis. Nineteen proximal tibial valgus and diaphyseal fibula osteotomies were performed on 15 knees. There was a 50% rate of recurrent deformity in males with clinical onset at less than or equal to 10 years of age. Females and older males had no recurrences. Histopathologic studies of the physis performed on one case demonstrated abnormal cellular islands of hyaline cartilage, small foci of necrotic cartilage, prominent intertrabecular vascularity, and premature medial physeal closure. These data support late-onset tibia vara as a distinct entity closely related to the infantile form. They also suggest three specific forms of tibia vara based on the age at clinical onset: infantile (0-3 years), juvenile (4-10 years), and true adolescent (11 years or older). The juvenile group is characterized by a high rate of recurrence following surgical correction, whereas the others are not.

Proximal tibial epiphyseal fracture in an infant

Proximal tibial epiphyseal fractures are rare injuries occurring predominantly in older children and adolescents. They have not previously been reported in infants. The present case is that of a 7-month-old female infant with a displaced Salter-Harris type II fracture secondary to child abuse. This represents the youngest documented case of a proximal tibial epiphyseal fracture. Open reduction and internal fixation were performed because of failure to obtain an anatomic alignment by closed reduction. The anatomic reason for unsuccessful closed reduction intraoperatively was found to be an infolding of the pes anserinus and periosteum. Tibia valga occurred postoperatively because of asymmetrical physeal overgrowth and required corrective osteotomy.

Innominate osteotomy in the management of residual congenital subluxation of the hip in young adults

The application of innominate osteotomy (IO) to persistent subluxation of the hip in adults is limited. Indeed, a relatively small percentage of such adults, particularly those in the fourth and fifth decades of life, meet the precise indications and essential prerequisites for IO. Nevertheless, in most carefully selected young adults in up to and including the fifth decade of life, IO has proved successful. The objective of IO is to prevent degenerative processes in adults with only potential arthritis, seeking arrest or even reversal of the progression of degenerative disease. IO is applicable only to adults who have arthritis in its earliest stages. Achievement of these objectives is dependent on adherence to the exact indications, prerequisites, and contraindications as well as to the details of the surgical technique as described.

Railyard amputations in children

Railyard or train-related accidents are a common cause of traumatic amputations in children. Four consecutive children with traumatic lower extremity amputations due to railyard amputation seen between 1975 and 1980 demonstrated: a common mechanism of injury--all were attempting to obtain rides on slow-moving trains near their homes or school; similar lower extremity amputation patterns--four right below knee and two left Syme's amputations; and distinctively abnormal psychosocial backgrounds. The psychosocial abnormalities have been demonstrated to be unique in children sustaining traumatic railyard amputations and are probably contributory. Awareness of these factors is important when considering surgical intervention and in planning for long-term rehabilitation.

Beta-adrenergic blockade and peripheral vascular disease

Hypertension and ischaemic heart disease are common accompaniments of peripheral vascular disease, and are often treated with beta-blocking drugs. Previous reports, however, have suggested that these drugs may aggravate peripheral vascular disease. A study was designed to investigate this problem with claudication-distance and skin and muscle blood-flow studies (as determined by 133Xe clearance) as indices for assessment. In all 11 patients who presented with features of peripheral vascular disease and were found to be taking beta-blocking drugs, administration of the drug was stopped, blood pressure was controlled by other means, and the situation was reassessed four weeks later. There was a significant improvement in claudication distance and in resting and post-exercise muscle blood flow after withdrawal of the drug. This held for both cardioselective and nonselective beta-blockers. It is recommended that this group of drugs be avoided in the treatment of patients with peripheral vascular disease.

Surgical management of resistant congenital talipes equinovarus deformities

We evaluated the results of surgery for resistant congenital talipes equinovarus deformity in 164 children (244 feet). No patient was followed for less than two years. They were divided into three groups for analysis, based on their treatment. Group 1 consisted of seventy-five children (112 feet) who had incomplete releases only; Group 2 consisted of twenty-three children (thirty-nine feet) who had had a failed incomplete release followed by a one-stage complete posteromedial plantar release, without internal fixation, and serial application of casts; and Group 3 consisted of sixty-six children (ninety-three feet) who had the complete posteromedial plantar release as the initial surgical procedure. Group 1 had 42 per cent, Group 2 had 79 per cent, and Group 3 had 86 per cent satisfactory (excellent or good) long-term results. The radiographic measurements that correlated best with the clinical results were the anteroposterior talocalcaneal overlap, the lateral talocalcaneal angle, and the positions of the navicular and calcaneus. The results in our series emphasize the complex interrelationship of the pathological anatomy and the need for complete simultaneous release of all components of the deformity.

Spontaneous atlantoaxial subluxation as a presenting manifestation of juvenile ankylosing spondylitis. A case report

Juvenile-onset ankylosing spondylitis is an unusual disorder which can present with either peripheral arthritis or with more classic hip girdle and back symptoms. Atlantoaxial instability has been recognized as a late complication in only one patient and has not been reported as an early manifestation. This paper presents a case in which atlantoaxial instability and neck pain without neurologic involvement was a presenting manifestation. The laboratory and clinical features of juvenile ankylosing spondylitis are discussed, along with the importance of qualitative sacroiliac joint scintigraphy in the diagnosis of early or confusing cases.

Preventive pediatric orthopedics

Prevention programs for pediatric orthopedic disorders are deficient in the United States today primarily due to a lack of knowledge about their incidence and ultimate disability. Open neural tube defects, Duchenne muscular dystrophy, cerebral palsy, spastic dislocation of the hip, congenital dislocation of the hip, and idiopathic scoliosis are common problems with preventable aspects. These facts should be known by all physicians involved in the care of children.

Erythromelalgia

Erythromelalgia is an extraordinary disorder of unknown etiology and pathophysiology that resembles the post-traumatic reflex dystrophy syndromes but has not been described previously in the orthopedic literature. Its distinctive triad of intense burning extremity pain associated with erythema and increased skin temperature are diagnostic. Primary or idiopathic and a secondary or associated form have been identified. The latter occurs in association with an underlying disease process, especially myeloproliferative disorders. Treatment with pharmacologic agents and surgery are ineffective except in the secondary group where treatment of the associated disorder generally results in a remission. Symptoms in the primary group can be minimized by appropriate environmental control with cooling and avoiding heat-producing situations that would raise skin temperature above a critical thermal threshold.

Legg-Calvé-Perthes disease: Results of discontinuing treatment in the early reossification phase

The major controversy in Legg-Calvé-Perthes disease concerns its treatment. All authors recognize the need for containment of the femoral head but do not agree on the method of containment. Surgical containment is constant, does not require an endpoint for discontinuing treatment and has a short treatment period. Conservative treatment, however, produces comparable results, avoids operative and anesthetic complications but requires prolonged immobilization. The concept of Ferguson and Howorth can be validated and indicates that when early subchondral reossification is present on both the anteroposterior and lateral roentgenograms that conservative containment treatment can be safely discontinued thus shortening outpatient time to 12 months or less. The results of 165 hips undergoing conservative treatment and 27 who received surgery are analyzed. Eighty-one conservatively treated hips were mobilized early and followed for an average of 5 years. Their results were identical to those treated until the time of complete restoration of the capital femoral epiphysis. This reduction in outpatient treatment and the decrease in potential complications minimizes several of the major arguments in favor of surgical management.

A quantitative review of the performance of implanted cardiac pacemakers, Medtronic Model No. 5944

One of the service functions of the Sir Charles Gairdner Hospital Department of Biophysics since 1972 has been the routine performance testing of pacemakers implanted by the Hospital's Cardiologists. This service was set up to measure pacemaker pulse parameters with a view to detecting battery depletion. It was also found to be of great help in showing lead insulation deterioration, intermittent capture and movement of the catheter tip within the right ventricle, information that is frequently of help to the Cardiologists in planning acute or elective pacemaker replacement.

Healed untreated anterior cervical spine dislocation. A case report

Fracture and fracture-dislocations of the cervical spine are serious injuries that rarely go undiagnosed. A case report of a bilateral facet dislocation with anterior displacement is presented that went undiagnosed and untreated, and healed without neurologic sequelae. No previous similar reports are known.

Vector cardiographic assessment of implanted cardiac pacemakers

The design and use of an on-line PDP 11/40 based vector cardiographic pacemaker assessment system is described. The system has been designed for comprehensive, automated testing of either fixed rate or demand implanted cardiac pacemakers. It is accurate and can be operated by a laboratory assistant without special training. Pacemaker parameters extracted are pulse height, width, rate, energy index and the frontal plane vector length and angle at maximum inspiration and during quiet breathing. In addition, a graphical representation of the patient's ECG and the pacemaker pulse is obtained on a computer graphics terminal. Patient data are written to cartridge disk for permanent record following the test. At each subsequent test of the implanted pacemaker, the data on disk are addended with the latest quantitative results. A separate off-line FORTRAN program can interrogate disk files for detailed analysis of patient data and display of parameter trends since implantation.