The Journal of Bone and Joint Surgery

Published by Journal of Bone and Joint Surgery, Inc
Online ISSN: 1535-1386
Print ISSN: 0021-9355
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A case series is a descriptive study that follows a group of patients who have a similar diagnosis or who are undergoing the same procedure over a certain period of time. As there is no experimental protocol or control for allocation of patients to treatment, surgeons and patients decide on whether or not treatment is given, making the clinical sample representative of a common clinical population. Results of case series can generate hypotheses that are useful in designing further studies, including randomized controlled trials. However, no causal inferences should be made from case series regarding the efficacy of the investigated treatment. This article will provide principles for the design, analysis, and reporting of case series, illustrated by examples from the orthopaedic surgical literature.
 
To The Editor: Bierbaum et al. should be commended for their extensive study entitled "An Analysis of Blood Management in Patients Having a Total Hip or Knee Arthroplasty" (81-A: 2-10, Jan. 1999), in which they question the utilization of preoperative autologous blood donation in current practice. The authors conclude that the most important predictors of allogeneic transfusion are a low baseline hemoglobin level and a lack of predonated units. They state that patients who predonate more blood are expected to receive fewer allogeneic units because of the availability of autologous units and conclude that preoperative autologous donation decreases the risk of allogeneic transfusion. This may not necessarily be true. Instead, patients predonating more autologous units are expected to have higher baseline hemoglobin levels. High baseline hemoglobin levels, regardless of the availability of predonated units, decrease the likelihood of allogeneic transfusion. The negative correlation between the number of autologous units predonated and the allogeneic transfusion rate implies, but does not prove, that predonation decreases the risk of allogeneic transfusion in patients managed with total joint arthroplasty. Their nonrandomized, uncontrolled, prospective study is flawed by preselection bias …
 
The efficacy of three prophylactic regimens against deep venous thrombosis was assessed in 135 patients who were more than thirty-nine years old and had a total hip replacement. The three regimens were 1.2 grams of aspirin daily, 0.3 gram of aspirin daily, and external pneumatic compression of the calf and thigh combined with low-molecular-weight dextran that was given for three days, beginning during the operation. In all patients, detection of fresh thrombi was by the fibrinogen-uptake test, cuff-impedance plethysmography, and venography. New venous thromboses developed in twenty-nine of forty-eight patients receiving 1.2 grams of aspirin and in twenty-six of forty-three receiving 0.3 gram of aspirin, indicating that the lower dose of aspirin had no advantage. Thromboembolic disease developed in only nine of forty-four patients who were on the regimen of external compression and dextran. This combination was significantly better than aspirin in both men and women. Dextran appeared to be associated with excessive bleeding when given in doses of more than 500 milliliters during the operation, but not when given in less than that amount.
 
Quantification of viable chondrocytes with use of confocal microscopy. Following fluorescent staining with propidium iodide (red, indicating dead cells) and CMFDA (green, indicating live cells), a serial z-axis image stack 720 · 540 mm was acquired from the articular surface of the center of the medial and lateral femoral condyles and the center of the trochlear groove to a depth of 25 mm. Image stacks were then reconstructed in threedimensional space. The percent cell viability was counted in each three-dimensional image.
Computerized quantification of histological sections. Following segmentation of the articular cartilage with use of customized histomorphometric software, the center of the trochlea, the medial femoral condyle, or the lateral femoral condyle was identified on each section. A line was drawn at the center, perpendicular to the cartilage surface, dividing the image into two halves (solid line). Each half section was again bisected, and a second line was drawn (dashed lines). The software was then used to generate three fullthickness cartilage regions of interest, centered on each line, of approximately equal size (;300 mm wide). The mean cell density was then calculated within each region of interest, and the densities were averaged for each histological section.
Gross assessment of chondral surfaces. The articular surfaces were smooth and glistening, with no visible surface irregularities, six months after a single intra-articular injection of normal saline solution (A) or 0.5% bupivacaine (B). In contrast, a single injection of 0.6% monoiodoacetate (MIA) (C) resulted in visible cartilage erosions.
Single intra-articular injections of local anesthetics are commonly used clinically. Recent in vitro studies have demonstrated chondrotoxic effects of local anesthetics, with the greatest emphasis on bupivacaine toxicity. This in vivo study was conducted to determine whether a single intra-articular injection of 0.5% bupivacaine results in chondrocyte morbidity and rapid chondrolysis. Forty-eight Sprague-Dawley rats received a 100-microL injection of sterile 0.9% saline solution (negative control) into one stifle joint and 100 microL of either preservative-free 0.5% bupivacaine (experimental group) or 0.6 mg/mL monoiodoacetate (positive control) into the contralateral joint. The rats were killed at one week, four weeks, twelve weeks, or six months. Live and dead cells were quantified with use of three-dimensional confocal reconstructions of fluorescent-stained tissues at standardized locations on the distal part of the femur. Histological findings were graded with use of a modified Mankin score, and cell density was quantified with use of custom image-analysis software. In the specimens injected with bupivacaine, the chondral surfaces remained intact as seen with gross and histological examination. No differences in superficial chondrocyte viability or modified Mankin scores were observed between the saline-solution and bupivacaine groups at any location or time point (p > 0.05). Quantitative histological analysis of the bupivacaine-treated knees at six months revealed an up to 50% reduction in chondrocyte density compared with that of the saline-solution-treated knees (p < or = 0.01). Monoiodoacetate injection resulted in death of up to 87% of the superficial chondrocyte cells at one week and chondrolysis at six months. Despite severe histological abnormalities by four weeks after monoiodoacetate injection, cartilage injury was not evident on gross inspection until six months. This in vivo study showing reduced chondrocyte density without cartilage tissue loss six months after a single intra-articular injection of 0.5% bupivacaine suggests bupivacaine toxicity. The effects of bupivacaine were milder than those of an injection of 0.6% monoiodoacetate, which resulted in chondrolysis over the same time period.
 
Aspiration biopsy is a method by which a high percentage of accurate diagnoses may be obtained, provided that the correct technique is followed and the material is examined by specialized pathologists. Of 1,061 aspirations, results were positive in 84.35 per cent. The method, which is simple, carries no risk to the patient and does not exclude other methods of diagnosis. It is particularly useful in deep locations such as the vertebral bodies or the pelvis. Aspiration biopsy of vertebral bodies may be considered as a definite advance which, because of its simplicity and safety, should become an accepted method of diagnosis.
 
MRI (magnetic resonance imaging) is widely used to diagnose meniscal pathology and ACL (anterior cruciate ligament) tears. Because of the enhanced signal-to-noise ratio and improved image quality at higher field strength, knee MRI equipment is shifting from 1.5 to 3.0 T. To date, objective evidence of improved diagnostic ability at 3.0 T is lacking. The purpose of this prospective study was to assess the accuracy of 1.5 and 3.0-T MRI of the knee, in the same individuals, for diagnosing meniscal pathology and ACL tears, utilizing arthroscopy as the reference standard. Two hundred patients underwent MRI of the knee at 1.5 and 3.0 T. All MRI examinations consisted of multiplanar turbo spin-echo sequences. One hundred patients underwent subsequent knee arthroscopy. Two blinded independent radiologists assessed all MRI studies to identify meniscal pathology and ACL tears. In patients with MRI results indicating the need for surgical treatment, the sensitivity and specificity of the 1.5 and 3.0-T protocols for detecting these lesions were determined, utilizing arthroscopy as the reference standard, and compared with use of the McNemar test. The kappa statistic for inter-reader agreement in the 200 patients was calculated. For medial meniscal tears, the mean sensitivity and specificity for the two readers were 93% and 90%, respectively, at 1.5 T and 96% and 88%, respectively, at 3.0 T. For lateral meniscal tears, the mean sensitivity and specificity were 77% and 99%, respectively, at 1.5 T and 82% and 98%, respectively, at 3.0 T. For ACL tears, the mean sensitivity and specificity were 78% and 100%, respectively, at 1.5 T and 80% and 100%, respectively, at 3.0 T. None of the values for either reader differed significantly between the 1.5 and 3.0-T MRI protocols. Inter-reader agreement was almost perfect to perfect (kappa = 0.82 to 1.00). Routine use of a 3.0-T MRI protocol did not significantly improve accuracy for evaluating the knee menisci and ACL compared with a similar 1.5-T protocol. Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
 
Patients who have major loss of bone in the region of the medial aspect of the femoral neck, shortening of the limb, or a high center of the hip joint constitute a special challenge for surgeons performing revision total hip replacements. The use of a so-called calcar-replacement femoral component is one approach to these problems. Of forty-eight hips (forty-four patients) that had been treated consecutively with a total revision arthroplasty with insertion of a calcar-replacement femoral component with cement, thirty-eight hips (thirty-five patients) were followed for a mean of 10.8 years (range, 5.8 to 16.6 years). Ten of the forty-eight hips did not qualify for this study, including nine hips in eight patients who had died before the minimum five-year duration of follow-up and one hip in a patient who had refused follow-up. Of the thirty-eight hips that were followed, seven (18 per cent) had had a repeat revision because of aseptic loosening of the femoral component, one (3 per cent) had been revised again because of lysis around a well fixed femoral component, and an additional four (11 per cent) had a component that was loose according to radiographic criteria. Thus, twenty-six (68 per cent) of the thirty-eight index femoral components were rigidly fixed according to radiographic criteria, and thirty (79 per cent) were still in place. The clinical results were very good for the thirty hips that had not been revised. The mean Harris hip-rating for these patients increased from 50 points preoperatively to 84 points at the most recent follow-up evaluation.
 
A study of 1000 consecutive grafts of flexor tendons in the fingers and thumbs has allowed us to develop a consistent technique and a system of evaluation. The first 300 were reported previously. Detailed analysis of the last 700 grafts, 607 in the fingers and ninety-three in the thumb, permits the following conclusions. Scarring from injury or additional scarring from inept previous surgery, or failed primary reparative procedures, compromised the results of secondary tendon grafting. Fingers in which joints had been damaged or in which the interphalangeal joints had become stiffened from neglect did not respond well to tendon grafting, even though the joints were mobilized well before surgery. In fingers with minimum scarring and only one nerve injured, the results were not impaired, but fingers with both nerves damaged had much less motion. The level of tendon injury, whether in the proximal, middle, or distal portion of no-man's land was not a determining factor on the result, nor was the time from injury to operation. Injury of the tendons in more than one digit in itself was not important. The condition of the individual digit determined the outcome for each finger. Other things being equal, patients over forty years of age did not obtain as much motion from tendon grafts as did the patients in younger age groups. The palmaris longus tendon was the best donor tendon, but there was little difference noted when a good superficialis tendon was used. The superficialis of the littie finger and the plantaris tendons are not recommended because of their small size and tendency to rupture. Pulley reconstruction done at the same time as the tendon grafting does not compromise the result. Loss of a few degrees of extension of the interphalangeal joints is not detrimental, but if the total loss of the two joints exceeds 40 degrees in the index or long fingers and 60 degrees in the ring or little fingers, the limitation of extension is significant. When a graft separates at the palmar junction or at its insertion, prompt resuture will salvage at least one-half of the digits. In flexor-tendon grafting in the thumb, the source of the donor tendon, the site of injury, and the presence of considerable scar do not affect the result adversely. The degree of nerve damage had only a minor effect on the result. Grafts extending from the musculotendinous juncture to the terminal phalanx gave better results than the shorter ones. Fingers treated by primary wound closure and insertion of a tendon graft as a secondary procedure had significantly better results than those treated by grafting after an attempted primary tendon repair had failed.
 
The present study evaluates the minimum five-year results of vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. The purposes of the present study were to review the results of fibular grafting in a large series of patients and to determine the indications for this procedure. Eighty-six patients (101 hips) were followed clinically for a minimum of five years (or until the time of death). The study group included fourteen Marcus-Enneking stage-2 hips, twenty-three stage-3 hips, and sixty-four stage-4 hips. Three patients (three hips) died from unrelated causes before the five-year evaluation, and two patients (two hips) died after the five-year evaluation. Radiographic assessment was performed with use of the Marcus-Enneking grading system, and clinical assessment was performed with use of the Harris hip-scoring system. The end point was conversion to total hip arthroplasty. Patient satisfaction was also assessed. Sixty-two hips (61%) survived until the time of the five-year follow-up, and forty-two hips (42%) survived until the time of the interview (at a median of eight years postoperatively). The average Harris hip score was 58 +/- 13 at the time of presentation and 80 +/- 15 at five years. Eight (57%) of the Marcus-Enneking stage-2 hips, sixteen (70%) of the stage-3 hips, and thirty-eight (59%) of the stage-4 hips survived for at least five years. Of the eighty-one living patients (including forty-one who had a successful outcome and forty who had had a failure), forty-six patients (including twenty-one who had a successful outcome and twenty-five who had had a failure) stated that they would undergo the procedure again. Vascularized fibular grafting may provide a chance for normal hip function in the intermediate or long term in carefully selected patients with osteonecrosis of the femoral head.
 
The natural history, associated anomalies, and response to operative and nonoperative treatment were reviewed in 102 patients with neurofibromatosis and spine deformity. Eighty patients were found to have curvatures associated with dystrophic changes in the vertebrae and ribs. The presence of dystrophic changes such as rib penciling, spindling of the transverse processes, vertebral scalloping, severe apical vertebral rotation, foraminal enlargement, and adjacent soft-tissue neurofibromas was found to be highly significant in prognosis and management. Brace treatment of dystrophic curves was unsuccessful. Posterior fusion, with or without internal fixation, was the procedure of choice for problems due purely to scoliosis. Patients with dystrophic kyphoscoliosis required both anterior and posterior fusion to achieve stability. Sixteen patients had compression of the spinal cord or cauda equina.
 
Background: There is limited Level-I evidence that compares operative and nonoperative treatment of rotator cuff tears. We compared outcomes of patients treated with primary tendon repair with outcomes of those treated with physiotherapy and optional secondary tendon repair if needed. Methods: A single-center, pragmatic, randomized controlled study with follow-ups after six months and one, two, and five years was conducted in a secondary-care institution. One hundred and three patients with a rotator cuff tear not exceeding 3 cm were randomized to primary tendon repair (n = 52) or physiotherapy (n = 51). The primary outcome measure was the Constant score. Secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score; the physical component summary measure of the Short Form 36 Health Survey; the measurement of pain, strength, and shoulder motion; patient satisfaction; and findings from magnetic resonance imaging and sonography. Analysis was by intention to treat. Results: The five-year follow-up rate was 98%. Twelve of the fifty-one patients in the physiotherapy group were treated with secondary tendon repair. The results from primary tendon repair were superior to those from physiotherapy plus secondary repair, with between-group mean differences of 5.3 points on the Constant score (p = 0.05), 9.0 points on the American Shoulder and Elbow Surgeons score (p < 0.001), 1.1 cm on a 10-cm visual analog scale for pain (p < 0.001), and 1.0 cm on a 10-cm visual analog scale for patient satisfaction (p = 0.03). In 37% of tears treated with physiotherapy only, there were increasing tear sizes on ultrasound of >5 mm, over five years, associated with an inferior outcome. Conclusions: Although primary repair of small and medium-sized rotator cuff tears was associated with better outcome than physiotherapy treatment, the differences were small and may be below clinical importance. In the physiotherapy treatment group, there were increasing tear sizes and inferior outcomes in one-third of patients who did not undergo repair.
 
A number of serious complications associated with fluoroscopically guided extraforaminal cervical nerve blocks have been reported in the literature. The purpose of the present study was to determine the rate of complications associated with these blocks and to determine whether needle positioning during the procedure affected the prevalence of complications at one institution. Between October 1999 and June 2003, we performed 1036 fluoroscopically guided extraforaminal cervical nerve blocks in 844 patients. Plain radiographs documenting the procedure were made as part of the standard quality-assurance protocol. An independent observer who was uninvolved with the procedures reviewed a prospectively kept database on all patients. We subsequently reviewed the patient records to identify complications. There were no catastrophic complications such as vessel damage, paralysis, or death. Overall, fourteen patients (1.66%) had a minor complication in association with the procedure. With the numbers available, the rate of complications associated with pdeep injection (798 blocks) was not significantly different from that associated with shallow injection (238 blocks) (1.89% compared with 0.84%). However, the rate of complications associated with anterior placement of the needle tip (thirty-three blocks) was higher than that associated with ideal placement of the needle tip (904 blocks) (6.06% compared with 1.55%) (p = 0.04). No catastrophic complications occurred in this series of 1036 nerve blocks. We found that the medial-lateral needle depth as seen on frontal-view radiographs was not associated with complications, although the anterior positioning of the needle as seen on lateral-view radiographs was associated with minor complications. Our results suggest that, with our technique, cervical nerve blocks are relatively safe procedures.
 
Aspiration biopsy of the spine should be considered an established procedure for diagnosing vertebral lesions as confirmed by the experience at my hospital with 1078 cases seen between 1939 and 1967. The general principles of aspiration biopsy, as well as its advantages and disadvantages, are discussed with particular reference to the thoracic spine between the second and ninth thoracic vertebrae, a region previously thought to be unsuitable for this procedure. If the aspiration is performed with the proper technique and instruments it is completely safe. No complications were observed in this series. The anatomical studies employed to develop the technique for aspiration biopsy of the thoracic spine are described as well as the results in twenty-eight thoracic lesions. In these cases the correct diagnosis was established in twenty-seven and no complications occurred.
 
From January 1979 to February 1982, 143 patients (79 women and 64 men) with 146 uninfected cemented total hip arthroplasties had revision cemented hip arthroplasty at The Hospital for Special Surgery for what was considered to be mechanical failure. The average age of the patients at primary arthroplasty was 56.1 years and at revision, 62.1 years. Loosening of the femoral component before revision correlated with varus positioning in 50% of the hips, inadequate cement in 34%, and a relatively young age in 16%. The average age of the patients (15 hips) with a loose femoral component that had been placed in a neutral or valgus position with good cementing technique was 48.2 years at the time of primary arthroplasty. Loosening of the acetabular component was attributed to high placement of the cup in 41%, inadequate bone in 18%, a vertical orientation of the opening of the cup in 7%, and poor cementing technique in 3%. Complications associated with revision included perforation of the femoral cortex in 13%, postoperative deep infection in 3.4%, postoperative dislocation in 8.2%, trochanteric complications in 6.2%, and sciatic palsy in 0.7%. Of the 139 hips that were followed for an average of 3.6 years (range, 2-5 years) after revision, the results were excellent in 59%, good in 7%, fair in 16%, and poor in 18%. After revision of the 139 hips, 29% showed progressive radiolucencies; 18%, femoral subsidence; and 9%, acetabular migration. Definite mechanical failure after revision was identified in 15.8% of the hips. These failures were due to loosening of 12.2% of the hips, femoral fracture in 2.2%, and disabling dislocation in 1.4%. At the time of follow-up, 12 hips (8.6%) had been revised a second time: 6 (4.3%) for loosening of one or both components, 3 (2.2%) for femoral fracture, and 3 (2.2%) for infection. Mechanical failure and progressive radiolucencies were associated with poor quality of bone (p < 0.001) and inadequate anatomical reconstruction (p < 0.03).
 
Longitudinal instability of the forearm (the Essex-Lopresti lesion) following radial head excision may be difficult to detect. This cadaveric study examines a stress test that can be performed in the operating room to identify injury to the ligamentous structures of the forearm. Twelve cadaveric upper extremities were randomized into two groups and underwent radial head resection. Group 1 underwent sequential transection of the triangular fibrocartilage complex and the interosseous membrane. Group 2 underwent sequential transection of the interosseous membrane and the triangular fibrocartilage complex. Ulnar variance and radial migration were examined with use of fluoroscopy of the wrist before, during, and after the application of a 9.1-kg load via longitudinal traction on the proximal part of the radius. Group 1 demonstrated no significant changes in proximal radial migration with load (compared with the findings after radial head resection alone) after transection of the triangular fibrocartilage complex. However, Group 2 demonstrated significant changes in proximal radial migration with load after transection of the interosseous membrane (p = 0.03; median, 3.5 mm). In both groups, transection of both the triangular fibrocartilage complex and the interosseous membrane resulted in significant changes in proximal radial migration with load (p = 0.001; median, 9.5 mm). When the load was removed, specimens were ulnar positive (median, 3.0 mm), with no specimen returning to the preload position of ulnar variance (p = 0.001). After radial head resection, 3 mm of proximal radial migration with longitudinal traction indicated disruption of the interosseous membrane. In all specimens, proximal radial migration of > or =6 mm with load indicated gross longitudinal instability with disruption of all ligamentous structures of the forearm.
 
Multiple treatment methods have been advocated for patellofemoral arthritis. The purpose of the present study was to report on our experience with the use of total joint replacement for the treatment of primarily severe patellofemoral arthritis of the knee in patients more than fifty-five years of age. Between January 1980 and December 1994, thirty knee replacements were performed in twenty-seven patients for the treatment of arthritis that primarily involved the patellofemoral joint. The Ahlbück radiographic evaluation scale was used to grade the severity of arthritis; the mean score was 4.83 points (range, 4 to 5 points) for the patellofemoral compartment and 0.6 point (range, 0 to 1 point) for both the medial and lateral compartments. The patients included eighteen women and nine men who had a mean age of seventy-three years (range, fifty-nine to eighty-eight years). None of the patients had had any prior procedures on the knee, but all had been treated for a minimum of six months with nonoperative measures. The mean preoperative Knee Society score was 50 points (range, 20 to 64 points). At a mean duration of follow-up of eighty-one months (range, forty-eight to 133 months), there were twenty-eight excellent, one good, and one poor result. The mean Knee Society objective score was 93 points (range, 67 to 100 points). The poor result was in a patient who sustained a rupture of the patellar tendon postoperatively as the result of a fall, which necessitated a tendon reconstruction. Total knee arthroplasty was found to be a viable treatment option in patients more than fifty-five years of age with primarily severe patellofemoral disease.
 
The upper and lower extremities are more exposed and mobile than the spine and trunk and, therefore, are fractured more often than the less exposed and better protected spine and trunk. The frequency of fracture, both closed and open, is then greater for the extremities than for spine and trunk. The statistics in this series show that the risk of open fracture is the same in 1955 as it was in 1937 (4 per cent). More fractures are amenable to successful operative treatment and more such fractures are being treated operatively. Fractures (new and old) have comprised approximately one third (31 percent) of the total cases seen in this practice of orthopaedic surgery and this proportion has remained the same from 1937 to 1956.
 
1. One hundred and ten cases (288 bones) of chondroma of the hand were reviewed. The lesions were classified into two types (monostotic or polyostotic) and five forms (central, eccentric, associated, polyostotic, and giant). 2. Eighty-seven hands (136 bones) with follow-up of more than two years after various types of surgical treatment were evaluated and generally excellent results were obtained.
 
The results of combined scintigraphy in which indium-111-labeled leukocytes and technetium-99m methylene diphosphonate were used were compared with the results of cultures of open bone at 102 sites of delayed union or non-union, to determine the effectiveness of this combination as a preoperative indicator of osteomyelitis. There were twenty-five true-positive, fifty-nine true-negative, eleven false-positive, four false-negative, and three indeterminate interpretations, yielding, for the diagnosis of osteomyelitis, a sensitivity of 86 per cent, a specificity of 84 per cent, an accuracy of 82 per cent, a positive predictive value of 69 per cent, and a negative predictive value of 94 per cent. There were few false-negative scans; false-positive results were most likely at a metaphyseal site adjacent to a joint in which there was post-traumatic arthropathy, at the site of a failed arthrodesis, and at the site of an unstable delayed union or non-union.
 
Malignant tumors of the proximal part of the fibula are rare. We sought to analyze the presenting characteristics, postoperative complications, and local recurrences of malignant tumors in the proximal part of the fibula in a large series of patients. We identified 112 histologically confirmed malignant tumors of the proximal part of the fibula from the time period between 1910 and 2007. The sex ratio was nearly equal (fifty-four male, fifty-eight female). The average age of the patients was 27.6 years, and the average follow-up period was 5.7 years. Osteosarcoma (44%) was the most common diagnosis. Pain (86%), palpable mass (51%), and peroneal nerve symptoms (12%) were the most common presenting symptoms. One hundred and three (92%) of 112 underwent curative surgical treatment. The two most common procedures were amputation in fifty (45%) of 112 patients and Malawer type-II resection in twenty-four (21%) of 112 patients. Deliberative sacrifice of the peroneal nerve was performed in seventy-four patients (66%). Postoperative complications occurred in fourteen (12.5%) of 112 patients, including wound issues (ten of 112), peroneal nerve palsy despite nerve preservation (two of twenty-nine), and posterior tibial artery thrombosis (two of 112). No long-term knee instability was seen in the fifty-three patients who underwent resection with lateral collateral ligament reconstruction. Fifty-six patients (50%) developed distant metastases and twelve (11%) had local recurrences. Osteosarcomas are the most common malignant tumor of the proximal fibula. Complication rates are modest and long-term knee instability was not seen in patients undergoing reconstruction of the lateral collateral ligament. Local recurrence following resection is not uncommon and metastatic dissemination is the main cause of death. This series represents the largest collection of such tumors for which there is extended follow-up and data on surgical complications. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
 
The subtalar extra-articular arthrodeses performed at the Texas Scottish Rite Hospital for Crippled Children in Dallas during the five-year period from 1955 through 1959 were reviewed. Of the 112 procedures done on paralytic valgus feet, forty-two feet (37.5 per cent) were judged to have unsatisfactory results. The chief complication was late varus deformity, which required one or more subsequent surgical procedures for correction. This complication has, to our knowledge, not been emphasized in any of the previously reported series. The cause of this complication was not the bone-block procedure itself but the combination of subtalar extra-articular arthrodesis with the simultaneous transposition of both peroneal muscles. This combination causes muscle imbalance with excessive inversion power which leads to progressive, severe, disabling, late varus deformity resistant to subsequent surgical correction. Therefore, we should like to emphasize that, certainly in younger children, both peroneal tendons should not be transplanted at the time of the subtalar extra-articular arthrodesis for paralytic valgus feet regardless of the existing inversion-eversion imbalance. Function of the peroneus longus should be retained to preserve active pronation and abduction of the fore part of the foot after the hind part has been stabilized by the arthrodesis.
 
A study employing questionnaires, per formed by the Musculoskeletal Tumor Society, sought to assess the accuracy of diagnoses made from the findings of biopsies, the incidence of complications as sociated with the biopsy procedure, the effects of errors in diagnosis and of complications on the patient's course, and whether these problems occurred with greater frequency when the initial biopsy was per formed in a referring institution or in a treating center. Each member of the Society was asked to submit data on twenty sequential, unselected, newly diagnosed pa tients with malignant primary tumors of bone or soft tissue who had had a biopsy and a subsequent definitive procedure. Twenty orthopaedic surgeons in sixteen treating centers submitted information on 329 patients with a wide range of diagnoses (but generally conform ing to the distribution of these tumors in the general population). The mean age of the patients was 36.5 years (range, two weeks to eighty-three years). Two hundred and twenty-two lesions were primary in bone and 107 arose in soft tissue. One hundred and forty three of the tumors were biopsied in the referring in stitution and 17 1, in the treating center. Analysis of the results of the study showed sixty (18.2 per cent) major errors in diagnosis and thirty four ( 10.3 per cent) non-representative or technically poor biopsies. Problems arose in the skin, soft tissue, or bone of the biopsy wounds of fifty-seven patients (17.3 per cent), and the optimum treatment plan had to be altered as a result of problems related to the biopsy in sixty patients (18.2 per cent). In fifteen patients (4.5 per cent) an unnecessary amputation was performed as a result of problems with the biopsy, and in twenty eight patients (8.5 per cent) the prognosis and outcome were considered to have been adversely affected. The biopsy-related problems occurred from three to more than five times more frequently when the biopsy was performed at a referring institution rather than in a treating center. On the basis of these obser * Read in part at the Annual Meeting of The American American Academy of
 
Radiographic and histological studies of sixteen massive retrieved human allografts were carried out after the allografts had been in situ for four to sixty-five months. The studies demonstrated that union between the allograft and the host took place slowly at cortical-cortical junctions by the formation of an external callus derived from the cortex of the host, and it took place more rapidly at cancellous-cancellous junctions by internal callus advancing from the host into the allograft. Internal repair took place very slowly, was confined to the superficial surface and the ends of the graft, and had involved only 20 per cent of the graft by five years. The deep unrepaired portions of the graft retained their architecture, and where bone cement had been used to fix a prosthetic stem or an intramedullary rod to the allograft, there was no evidence of resorption of bone or loosening of the device. Soft tissues of the host became attached to the graft by deposition of a thin seam of new bone on the surface of the graft. A previous fracture of two grafts had healed before the time of retrieval. Analysis of the articular cartilage revealed no evidence that any chondrocytes had survived, even when the graft had been cryoprotected before it was preserved by freezing. The necrotic cartilage functioned well for as long as five years, and as it degenerated, it was covered by a pannus of fibrovascular reparative tissue. Two allografts that had been removed because of rejection were surrounded by an envelope of chronic inflammatory tissue that prevented union, adherence of soft tissue, and internal repair. Internal repair was more advanced about sites of fracture and adjacent to recurrent tumors than in other portions of the graft. These findings suggest that large frozen allografts in humans are osteoconductive rather than osteoinductive.
 
The primary objective of this prospective randomized controlled trial was to compare functional and quality-of-life indices and rates of revision surgery in arthroscopic rotator cuff repair with and without acromioplasty. Eighty-six patients consented and were randomly assigned intraoperatively to one of two study groups, and sixty-eight of them completed the study. The primary outcome was the Western Ontario Rotator Cuff (WORC) index. Secondary outcome measures included the American Shoulder and Elbow Surgeons (ASES) shoulder assessment form and a count of revisions required in each group. Outcome measures were completed preoperatively and at three, six, twelve, eighteen, and twenty-four months after surgery. WORC and ASES scores improved significantly in each group over time (p < 0.001). There were no differences in WORC or ASES scores between the groups that had arthroscopic cuff repair with or without acromioplasty at any time point. There were no differences in scores on the basis of acromion type, nor were any interaction effects identified between group and acromion type. Four participants (9%) in the group that had arthroscopic cuff repair alone, one with a Type-2 and three with a Type-3 acromion, required additional surgery by the twenty-four-month time point. The number of patients who required additional surgery was greater (p = 0.05) in the group that had arthroscopic cuff repair alone than in the group that had arthroscopic cuff repair and acromioplasty. Our findings are consistent with previous research reports in which there was no difference in functional and quality-of-life indices for patients who had rotator cuff repair with or without acromioplasty. The higher reoperation rate was found in the group without acromioplasty. Further study that includes follow-up imaging and patient-reported outcomes over a greater follow-up period is needed.
 
In a double-blind study of fifty patients that was done to test the ability of epidural morphine to decrease the discomfort after lumbar laminectomy, we found that during the first postoperative day the patient's pain was lessened appreciably but that the total dose of morphine received postoperatively was not diminished. We used a three-milligram dose of epidural morphine, and there were no problems with respiratory depression. The addition of epinephrine to the morphine solution had no beneficial effect.
 
To test the traditional classification system of slipped capital femoral epiphysis, we evaluated the presenting symptoms and radiographs of fifty-four patients and reclassified the slipped epiphyses as unstable or stable, rather than acute, chronic, or acute-on-chronic. Slips were considered to be unstable when the patient had such severe pain that weight-bearing was not possible even with crutches. Slips were considered to be stable when the patient could bear weight, with or without crutches. We reviewed the records on fifty-five hips in which the slip would have been classified as acute because the duration of symptoms was less than three weeks; thirty of these were unstable and twenty-five were stable. All slips were treated with internal fixation. A reduction occurred in twenty-six of the unstable hips and in two of the stable hips. Fourteen (47 per cent) of the thirty unstable hips and twenty-four (96 per cent) of the twenty-five stable hips had a satisfactory result. Avascular necrosis developed in fourteen (47 per cent) of the unstable hips and in none of the stable hips. We were not able to demonstrate an association between early reduction and the development of avascular necrosis.
 
The records of 224 children who had a slipped capital femoral epiphysis and who had no underlying metabolic or endocrine disorder were studied retrospectively to investigate the epidemiology of bilateral slipped capital femoral epiphysis. Eighty-two (37 per cent) of the 224 children (fifty-one boys and thirty-one girls) had a bilateral slip. Sixty-four of these children were black and eighteen were white. The age at the time of the diagnosis of the first slip was 13 +/- 1.7 years (mean and standard deviation), the duration of the symptoms was 5 +/- 5.0 months, and the angle of the slip was 26 +/- 16 degrees. Obese children were younger at the time of the diagnosis of the first slip (12 +/- 1.6 compared with 13 +/- 1.6 years for the children who were not obese, p = 0.001). The diagnosis of a slipped capital femoral epiphysis was made simultaneously in both hips in forty-one children and sequentially in forty-one children. Compared with the children in whom both hips were diagnosed simultaneously, the children in whom the hips were diagnosed sequentially had had a shorter duration of the symptoms before the diagnosis of the first slip (3 +/- 2.4 compared with 7 +/- 5.9 months, p = 0.0003), were younger at the time of the diagnosis of the first slip (12 +/- 1.9 compared with 13 +/- 1.2 years, p = 0.001), and tended to be more obese (p = 0.025). In 88 per cent of the patients who had sequential slips, the second slip was diagnosed within eighteen months after the diagnosis of the first slip.(ABSTRACT TRUNCATED AT 250 WORDS)
 
Leiomyosarcoma is an uncommon tumor that affects 500 to 1000 patients in the United States annually. The purpose of our study was to further define survival rates as well as to identify multivariable predictors of disease-specific mortality, local recurrence, and development of distant metastasis following surgical resection. We studied a consecutive series of patients treated for leiomyosarcoma at our institution (a tertiary-care referral center) over a ten-year period. Only patients with leiomyosarcoma of soft tissues, vasculature, or bone were included. Those with uterine, gastrointestinal, or cutaneous forms of the disease were excluded. This yielded a cohort of 115 patients with complete follow-up data on which statistical analysis was performed. One-year, five-year, and ten-year disease-specific survival rates were 87%, 57%, and 19%, respectively. Tumor depth (p < 0.01), histological grade (p < 0.01), and metastasis at presentation (p = 0.03) were found to be multivariable predictors of mortality. Both retroperitoneal location (p = 0.01) and mitotic rate (p < 0.001) were predictive of distant metastasis. Resection margin was the only multivariable significant predictor of local recurrence in the group treated with surgical resection (p < 0.001). Leiomyosarcoma is an aggressive disease, with a generally poor prognosis. Depth of tumor and high histological grade are indicators of a poor prognosis. Retroperitoneal tumors have a particularly high potential to metastasize.
 
The superiority of mobile-bearing total knee arthroplasty implants over fixed-bearing implants, or vice versa, is still debated. A series of patients with similar clinical and radiographic characteristics were treated consecutively with 100 fixed-bearing followed by 100 rotating-platform implants. Patients underwent prospective clinical and radiographic evaluation. The mean duration of follow-up was 116 months (range, sixty-one to 144 months). Clinical, radiographic, and implant survival outcomes were compared. No significant differences between the mobile-bearing and fixed-bearing groups were found with respect to the clinical outcome or cumulative implant survival at the time of the latest follow-up. Three of the fixed-bearing implants and one of the rotating-platform implants had required revision surgery. No differences between mobile-bearing and fixed-bearing designs were demonstrated at a mean of 116 months of follow-up. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
 
The treatment of chronic radial head dislocation remains controversial. High rates of redislocation and complications have been reported after surgery. In our view, correction of malalignment with ulnar osteotomy is the key to a good surgical result. Since 1975, twenty-two patients were treated surgically for chronic radial head dislocation at our hospital. The procedure consisted of open reduction of a dislocated radial head followed by radial and/or ulnar osteotomy, with or without reconstruction of the annular ligament or by reconstruction of the annular ligament alone. The ages of the patients ranged from four to twenty years. In 1991, we modified the surgical technique by performing an oblique ulnar osteotomy with angulation and elongation and rigid plate fixation. Bone-grafting at the osteotomy site was also performed if necessary. A cast was applied with the forearm in neutral rotation and was worn for two to four weeks. Nine patients were treated with this modified technique. The mean interval between the initial injury and the reconstructive surgery was ten months. There were no serious surgical complications. Of the thirteen patients treated before 1991, four had a good reduction and seven had redislocation. Seven patients had restricted forearm rotation postoperatively. Of the nine patients treated with the modified osteotomy since 1991, seven had a good reduction. Two patients, who had had slight radial head deformity preoperatively, had subluxation postoperatively. Two patients had restricted forearm rotation. Since we modified our technique for ulnar osteotomy, good reduction of the radial head has been achieved without causing serious contracture. Both angulation and elongation of the ulna are required to allow the radial head to reduce.
 
Top-cited authors
Javad Parvizi
  • Rothman Orthopaedic Institute
Kevin Bozic
  • Dell Medical School at the University of Texas at Austin
David C Ring
  • Dell Medical School -- University of Texas Medical School
Robert F LaPrade
  • Twin Cities Orthopedics
Steven M Kurtz
  • Drexel University