Increased platelet activation and decreased fibrinolysis in the pathogenesis of aseptic necrosis of the femoral head

Thrombotic events, increased tendency toward intravascular thrombosis and decreased fibrinolysis seem to be possible pathologic causes for aseptic necrosis of the femoral head (ANFH) in adults. This project was to study whether either increased platelet activation or decreased fibrinolytic activity and/or any other thrombogenic factor may be implicated in the evolvement of ANFH. The speed of the in vitro lysis was significantly lower in patients (both in primary and in secondary cases) compared with healthy controls. The platelet activation (measuring with beta TG) proved to be significantly higher in the primary group as well as in the secondary group compared with healthy controls. Lp(a) levels were elevated in primary and secondary cases. This alteration was more characteristic in the primary cases. Fibrinogen levels were also elevated in the primary group, but the difference was not significant. The data shown here may further support that hypofibrinolysis and increased thrombogenesis are major causes of ANFH. Early diagnosis of ANFH increases the chances of modifying the course of this disabling disease.

The most severe forms of Perthes' disease associated with the homozygous Factor V Leiden mutation

It has recently been postulated that thrombophilia may have a role in the aetiology of Perthes' disease. The published reports, however, remain conflicting. In this study a retrospective analysis of the coagulation parameters was made in 47 patients with Perthes' disease and the results compared with the clinical data. Five patients with Factor V Leiden mutation were found (10.6%) and surprisingly four of them had a homozygous pattern. These four patients showed the most severe form of the disease, Catterall group IV, with flattening of the entire epiphysis, involvement of the metaphysis, shortening and broadening of the femoral neck, trochanteric overgrowth and developed mushroom-shaped aspherical laterally displaced femoral heads in dysplastic acetabula. We would like to suggest that the homozygous form of Factor V Leiden mutation has some role in the clinical course of Perthes' disease and particularly its most severe form.

Multilevel callus distraction: a novel idea to shorten the lengthening time

Lower extremity inequality is a common problem in everyday orthopaedic practice. The leg discrepancy can lead to variety of other problems, i.e., spinal problems. Surgical intervention is very demanding and requires patient compliance. Wagner's and Ilizarov's elongation technique are most commonly used worldwide, but it gives satisfactory results only in a long period of time and as we know there could be several inconvenient outcomes. Our idea aims at shortening this time period, and avoiding some of the inconvenient outcomes. Unfortunately we do not have the opportunity to go further in our investigations, but we hope that someone interested in this field will have an idea which would make continuation possible.

Contradictions of derotation in scoliosis surgery using the CD principle

Current literature has increasingly emphasized the problem of derotation in scoliotic deformities. The Cotrel-Dubousset (CD) principle as a means of correcting rotation has been questioned by various authors. This paper aims to draw attention, using algebraic methods, to the importance of the remaining rotational deformities, and to suggest the introduction of the notion 'rotational balance'.

The 'rotational preconstraint'

This model provides a novel view of the etiology of some scolioses and can answer some of the biomechanical questions regarding pathogenesis of dorsal curves. According to our findings, paravertebral muscular imbalance is likely to favour such a pathological condition which, with the interference of the postural reflexes and the body weight-related vertical loading, might lead to the formation of a true scoliotic curve. Review of earlier research studies in the light of our findings reveals controversy in some authors' reported results and their own interpretations and seems to generally support our theory.

The importance of arthroscopy in diagnosing synovial haemangioma of the knee joint

In connection with one of their cases, authors call attention to the importance of differential diagnosis in synovial haemangioma of the knee joint, a rare condition. They also give a survey of its clinical, radiological and pathological features, review the literature on the topic, with special emphasis on the importance of arthroscopy in making the clinical diagnosis, and describe the treatment applied in their case.

Functional improvement after knee arthroplasty without resurfacing of patella

There has been no universal agreement so far regarding the necessity of patellar resurfacing in total knee arthroplasty. As resurfacing has been reported to be associated with high incidence of complications, this practice has been avoided in our Department. A report is given on the analysis of the functional outcome of 60 knee arthroplasties without patellar resurfacing in 53 patients (7 bilateral) followed up for twelve to thirty months, with special regard to the functions closely related to patelloformal articulation. The underlying diagnosis was osteoarthritis in 78.3%, rheumatoid arthritis in 13.3%, and posttraumatic arthritis in 8.3% of the patients. Graded according to the modified knee-rating system of the Hospital for Special Surgery, excellent or good results were obtained in the case of 55 knees (91.6%) and the mean score improved from 53.6 points preoperatively to 82.6 points following arthroplasty. Subjective and objective functional assessment of stair climbing and transfer activities have shown no functional deficit attributed to the patellofemoral joint of the replaced knee.

Experimental studies for the surgical correction and fixation of dorsal spine deformities

One of the specific features of the scoliosis operations with a posterior approach is that both the correction of the deformity and then the maintaining of the corrected situation are carried out with the help of the implants. With the currently applied systems based on the CD principle it is still difficult to control the rotational component of the scoliotic curve. To complement the systems based on the CD principle, we have developed an implant family whose application makes the correction of the dorsal deformity generally simplier and derotation more effective. Our method is based on the application of such hooks which, linked to the longitudinal rods and hooked on both transverse processes of the instrumented vertebrae, transmit the concerted forces exerting their influence in the direction of the correction. Depending on their symmetrical relations, the hooks are capable of tilting in the frontal plane and derotating in the horizontal plane simultaneously, in the direction of our choice. The stability and applicability of the hooks were tested in implants into cadavers, and then the intimate relations of the implants were examined by means of radiological tests and dissection on instrumented specimens. On the basis of our results, the implants can already be used in clinical practice.

Idiopathic scoliosis--new surgical methods or search for the reasons

Idiopathic scoliosis (IS) is a deformity of the spine whose aetiology is unknown despite of extensive clinical and basic research work. The significance of this disease lies in the consequences of a spine deformity (deformation of the chest, compromise of the cardio-pulmonar function, compression of the neurological elements, severe somatic and psychological sufferings). According to statistical data, one third of the idiopathic scoliotic cases progress and need surgical intervention. Cotrel and Dubousset introduced the three dimensional correction surgical method for the treatment of spine deformities in 1983 (CD method). The authors report on the application of the CD method for the treatment of IS from 1991 to date. After the operation of 36 patients they give an account of good results and report on the modifications of the surgical technique on the basis of their experiences. Aware of the late consequences of the surgical treatment of IS the authors started with the investigation of the aetiology of the disease in order to introduce a causal treatment. As for the aetiological background of IS, data on the role of heritable factors were relevant only. They gave a hint to start with studies aimed at the investigation of genetic determinants of the syndrome. I aberration of chromosome #10 [karyotype: inv(10)(p11q26)]. In one of the cases there was a multiple familial occurrence of the syndrome coupled with the same anomaly of the karyotype. The probands' father and grandfather all had the same pattern of scoliotic deformity and the same aberrant karyotype of chromosome #10 was found both in the proband and his father. Preparation of genomial DNA from peripheral blood of the patients was started. Fragment length polymorphism (RFLP) examination with PCR technique using oligonucleotide primers specific for chromosome #10 and for regulatory genes of left-right body assymetry is underway.

Efficacy of prevention of thromboembolic complications with LMW-heparin in experiment

The authors used an antithrombotic agent (Nadroparin Calcium) with anti-Xa effect in their experiments to prevent thromboembolic complications in the model of endoprosthetic replacement of the hip joint in mongrel dogs. 10 experimental animals (Group I.) were given doses of 100 A Xa ICU/kg/bwt of Nadroparin Calcium subcutaneously 4 hours prior to the operation and also once a day until the 3rd postoperative day; between the 4th and 10th postoperative days doses of 150 A Xa ICU/kg/bwt Nadroparin Calcium were given. The 10 control animals (Group II.) did not receive anticoagulant treatment. In both groups platelet count, activated partial thromboplastin times (APTT), prothrombin and fibrinogen levels as well as activated factor X inhibition (F Xa) were measured prior to surgery and also until the 14th postoperative day. No changes in APTT and prothrombin levels were detected during the experiment, however platelet count and fibrinogen levels as well as the extent of F Xa inhibition showed significant and different changes in groups I. and II. The Group I. which had received thromboembolic prophylaxis did not develop deep venous thrombosis or pulmonary embolism, but the control group did. Based on their investigations, the authors concluded that they had been able to achieve F Xa inhibition by giving the above mentioned doses of Nadroparin Calcium which was enough to prevent thromboembolic complications in their model experiment of implanting hip endoprosthesis.

Therapeutic value of continuous passive motion after anterior cruciate replacement

The aim of this study is the evaluation of the therapeutic value of continuous passive motion after ACL replacement. After 41 ACL reconstruction in 13 cases only active motion, in 28 cases active motion and CPM were used postoperatively. Stability, the range of motion and complications were evaluated at the time of discharge, 3 and 6 months after the operation. The flexion-extension in the CPM group was significantly greater at the time of discharge, but this difference was practically eliminated in 6 months after the operation. There were not any other significant difference between the two groups. The CPM gives only a little advantage in the rehabilitation after the ACL replacement.

Pemberton's pericapsular osteotomy for the treatment of acetabular dysplasia

We present the results of 80 Pemberton procedures carried out between 1977 and 1990. The patient age at the time of operation ranged between 2 and 12 years, and follow-up was between 1 and 15 years. Before Pemberton's operation, conservative treatment, closed and open reduction, and derotation femoral osteotomy were used. Pemberton's operation was combined with intertrochanteric femoral osteotomy in 30 cases. The mean values of the acetabular and center edge angle of Wiberg showed postoperative improvement of 19 and 17 degrees, respectively; whereas at follow-up, improvement was 20 and 23 degrees, respectively. Radiologically, 79% of the cases met Severin's classification grade I-II criteria. Clinically, 81% were classified as excellent and good. The results were closely correlated with ischemic necrosis due to preoperative treatment. Only patients belonging to groups II-IV of Kalamchi and MacEwen, plus one patient operated on at relatively old age (12 years), were found radiologically to be in Severin's groups III and IV. The results among patients operated on before age 7 were more favorable than those of patients operated on at an older age.

Preliminary results of early open reduction by an anterior approach for congenital dislocation of the hip

We report the results of 113 early open reductions of congenitally dislocated hips using a technique we have developed. Surgery is followed by functional postoperative treatment with a Pavlik harness or abduction splint. The age of the patients and the follow-up period ranged from 6 to 24 months and 2 to 12 years, respectively. Radiologic results corresponded to Severin grades I and II in 98%. Severe ischemic necrosis was not observed. Secondary surgery (femoral derotation osteotomy and/or Pemberton's operation) was performed in 21% of the cases. Reduction at a young age resulted in fewer secondary procedures. Good results were attributed to postoperative treatment: Abandoning rigid fixation prevented soft tissue stretching, which may endanger blood supply to the joint. This treatment ensures concentric reduction and allows early and spontaneous joint mobilization in a functional position. These factors stimulate further joint development.

[Indication for Chiari's pelvic osteotomy]

The results of 61 Chiari's pelvic osteotomies carried out during a 10 years period are reported. Present role of the operation in the correction of acetabular dysplasia in comparison to Pemberton's acetabuloplasty, to triple pelvic osteotomies and to the prosthetic replacement of the hip joint is discussed. In conclusion the operation is still indicated in special cases. Depending on the age of the patients pain can be observed already after 3-5 years however a great part of the patients is completely free of complaints even 10 years postoperatively.

A new surgical approach in 8 cases of polygonal triple pelvic osteotomy

We have undertaken 12 polygonal osteotomies, using an improved approach in 8. The operation was successful in correction of acetabular dysplasia after ossification of the triradiate cartilage. It was also useful in early arthrosis with slight deformity of the femoral head.

[Surgical-technical problems of triple pelvic osteotomy. Early results of the polygonal method]

Since the first description of the triple pelvic osteotomies papers reporting on the improvement of the operative technique were continuously published. This is explained by the more problematic details of the operation. Authors worked out to the technique of the polygonal triple pelvic osteotomy, published by Kotz, Dávid and Uyka, a new exposure that makes more simple, quick and safe the performance of the operation. The essential feature is that the os ischii is reached after the osteotomy of the trochanter major from a lateral exposure and so the field of operation can be widely surveyed. At the same time transposition can also be performed. The experiences gained in 12 operations are reported, 8 of which were made according to their own method (follow-up: 8-22 months, in average 15 months). The patients were 14-33 years old and their complaints disappeared in every case. Authors suggest the operation for the correction of the dysplastic acetabulum in young adults and also in puberty after the fusion of the Y cartilage if no subluxation exists. Minor articular deformity and mild arthrosis are not considered as a contraindication.

[Measuring the looseness of the knee joint by using the Kt 1000 arthrometer]

Authors measured the stability in the sagittal plane of the intact knee joints of 50 young men with the MEDmetric KT 1000 apparatus. The greatest movement during the measurements on 100 knees was observed in 25 degrees flexion and during the application of force 89N. In 70 degrees flexion the movement was only half of that observed in 25 degrees flexion. The difference of the average movements measured bilaterally was neither in active nor in passive experiments more than 0.5 mm. The difference between the average values of the compliance indexes on the left and right side was only 0.01 mm. In all measurements the frequency distribution of the differences between the two sides was essentially the same. The difference between the movements on the two sides did not exceed 2 mm-s in 90-100 percent of the cases.

Results of surgical treatment of knee instabilities

Between January 1, 1981 and January 5, 1987, 146 reconstructive operations for acute (39) and chronic (107) knee instabilities were performed. THe majority of the acute cases were anteromedial (24), and of the chronic instabilities, 33 were anteromedial, 14 anterolateral, and 53 combined anteromedial-anterolateral. In terms of suture, replacement, and reinforcement of the damaged structures of the acute cases, 32 were good, 6 fair, and 1 poor, while the reconstruction, according to Müller, for chronic instabilities produced good results in 34, fair in 59, and poor in 14. It is essential that such operations be performed by a trained surgical team. For success, precise knowledge of anatomy, exact examination, accurate diagnosis, adequate surgical techniques, and careful postoperative treatment are essential.

Surgical treatment of pathologic fractures from metastatic tumors of long bones

Surgical treatment of 74 cases of impending and established metastatic pathologic fractures were analyzed. On the basis of various reports, the incidence of bone lesions, bone-seeking primary tumors, lesion sites, diagnostic techniques and possibilities, as well as indications for and methods of surgical treatment, are surveyed. Surgical intervention is only one aspect of the different components of general treatment in bone metastases. An aggressive surgical procedure yields very satisfactory results in most cases, compared with those of conservative treatment.

The effect of early anterior approach open reduction with functional postoperative treatment on the early development of the acetabulum in CDH

Between 1980 and 1983, 30 anterior approach open reductions were performed on congenitally dislocated hips of 29 patients after unsuccessful conservative treatment; patients were between 6 and 18 months old. After the removal of the obstruction from the acetabulum, the reduction was performed with preservation of the limbus. Some part of the capsule was removed to constrict and tighten it and to prevent redislocation. This capsuloplasty demonstrates the success of a Pavlik harness and abduction splint postoperatively, without plaster fixation. The accelerated development of the acetabulum could be observed on radiograph by this functional treatment, compared to the control group treated with the usual hip spica postoperatively. The development of the acetabulum on the operated side almost equals the sound side within a year. If the operation was performed earlier, joint development would be quicker.

[Suture of the meniscus in acute instability of the knee joint]

The authors describe a multiform function of the menisci and the causes of frequently occurring simultaneous injuries of the meniscus and of the ligament. In 26 cases of acute instability of the knee the authors put sutures over the meniscus. In all the cases the results were good, there were no complications and there was no need to make a repeated operation in any of the cases. Making use of the suture over the meniscus, it is possible to improve the results of the surgical treatment of instability of the knee to a greater extent.

[Clinicopathology of bone metastases causing pathological fractures]

Of malignancies occurring in bones, metastatic tumours are the most frequent. Due to the increase of mean life span and to other factors the incidence of tumours is growing. Nevertheless, survival chances of patients suffering from tumours are also improving due to advance in diagnostics and to the application of complex therapy. These trends have substantially increased the number of recognized and manageable bone metastases. In general, life expectations of a tumour-patient are determined by the metastases therefore, the question of diagnostics and management of bone metastases is worth of special attention. Authors have performed a clinicopathological survey of patients of the past eight years who have suffered fracture due to bone metastases and were treated surgically. In one-third of the patients the primary tumour was unknown at the time of the fracture. On the basis of the histological pattern the detection of the parent-organ, particularly in adenocarcinomas, was not possible. Independently from the radiological appearance of the metastasis simultaneous osteogenesis and osteolysis were histologically observed.

Reoperation in treatment of clubfoot

We evaluated 118 operations (including 57 reoperations) on clubfeet. We concluded that relapse is most often the consequence of insufficient primary surgery, and the less sufficient the intervention, the more severe the relapse or residual deformity. The severity of deformity is determined and shown, first of all, by the position of calcaneum. In milder cases, soft tissue operation can prove useful, whereas more severe cases require bony intervention as well. The second, rarer cause of relapse was the fact that the foot was originally stiff and nonreducible. These feet may need multiple reoperations.

Spondylolysis in osteopetrosis

We report the occurrence of spondylolysis and/or spondylolisthesis of the lumbar vertebrae in five patients with osteopetrosis, four of them having multiple lesions. The case histories indicate that spondylolysis had developed in the pathological bone as a result of increased stress and that it is an acquired lesion.