Anders Hulth

Femoral-head Phlebography: A Method of Predicting Viability

The femoral head is supplied by the medial femoral circumflex artery and the obturator artery, and the supply is chiefly characterized by the prolonged intra-articular course of the vessels, partly in folds of the synovial membrane and partly in the ligamentum teres. The vessel branches to the head are comprised of parallel arteries and veins. Trochanteric fractures course lateral to the medial circumflex vessel, as distinguished from the fractures of the true neck, all of which are medial to this vessel. In the former type of fracture, therefore, this vessel with all its branches remains on the central fragment, while in neck fractures its branches must bridge the fracture in remnants of the synovial membrane.nn[See figure in the PDF file]nnThe method described for the performance of intra-osseous phlebography of the femoral head in neck fractures makes it possible to study the residual vascularity of the head fragment in different types of fractures. The types of venograms in neck fractures are positive in which the circumflex and ligamentum teres veins are filled with contrast material, and negative, in which no venous filling occurs. The negative venogram indicates avascularity but a good position of the cannula is required to show this.nnNon-displaced fractures differ from displaced fractures mainly in that in the former the remaining circumflex vascularization is considerably better. There are fewer cases of this type of vascularization among patients with displaced fractures and in these the circumflex vascularization is usually limited to the inferior retinacular vessels. In these displaced fractures there is instead a ligamentum teres type of vascularization to a large extent, especially in older patients.nnForty-three patients with displaced neck fractures examined venographically were followed. There were twelve negative venograms which all showed early signs of necrosis. There were thirty-one patients with positive venograms of whom ten eventually showed manifestation of necrosis but a different type than the necrosis found after negative venograms. The method herein described makes possible the early definitive diagnosis of avascularity in at least half of the patients in whom it will later occur.

Experimental retardation of endochondral growth by papain.

(1958). Experimental Retardation of Endochondral Growth by Papain. Acta Orthopaedica Scandinavica: Vol. 28, No. 1-2, pp. 1-21.

Studies on amputation stumps in rabbits.

Twelve rabbits weighing between 14 and 3 kilograms were submitted to amputation of a limb under nembutal anaesthesia. The amputation was performed at a site between the upper and middle portions of the tibia. In all cases the soft tissues were sutured with catgutaround the bony stump and the vessels were tied with plain catgut. All the rabbits withstood the operation quite well and after it moved about freely in their cages. The rabbits did not stand on the stumps either at rest or when walking. Angiography-At various intervals up to twelve weeks after amputation angiography was performed by a method previously described (Hulth and Olerud 1960). Through a cannula inserted by way of the carotid artery, 8 millilitres of 76 per cent Urografin (Schering) was injected, after which a single radiograph of the trunk and legs was taken. Microangiography and microradiography-Immediately after angiography laparotomy was performed and the abdominal aorta was exposed and ligated. For microangiographic purposes approximately 20 per cent Micropaque solution was injected distally by an ordinary infusion apparatus with a pressure ofjust under 100 centimetres ofwater. The technique used here was basically the same as that described by Trueta and Harrison (1953). The animals usually died some minutes after the beginning of the infusion but the time of infusion was always extended to sixty minutes. After ligation of the aorta and inferior vena cava the rabbit was cut in two at mid-trunk level, the distal parts being placed in 10 per cent formaldehyde for twenty-four hours. After deep freezing (-20 degrees Centigrade at least for twenty-four hours) suitable portions were excised for further formaldehyde fixation. This material was then dehydrated and embedded in methylmethacrylate. A band saw was used to cut slices one millimetre thick. These pieces were ground to a thickness ofabout 200 microns and subjected to microradiography (Engstrom 1957). It was possible therefore to study in all samples both the mineralisation of the callus and the microangiographic patterns. RESULTS Arteriography in vivo with Urografin-Figures 1 and 2 show the arteriographic patterns in the lower limbs respectively two and twelve weeks after amputation. The femoral artery of the stump did not appear narrower even though it had considerably less tissue to nourish. Even after the stump had healed and the growth of the callus was complete, the arterystill appeared

Coxa plana in the dog.

The authors describe coxa plana in the dog with the aid of clinical examination, roentgenograms, histological examination, and microangiographs. In both dog and man the condition appears basically to be an aseptic necrosis in the capital femoral epiphysis with all its typical histological characteristics. Microangiography reveals the non-vascular state of the epiphysis together with hypervascularization of all the surrounding tissue. The hypervascularization probably represents an attempt to revascularize the dead bone, but this is delayed by the capital femoral epiphysis being poorly accessible to blood vessels because of the articular cartilage and the avascular epiphyseal cartilage.

Effect of cortisone on the epiphysial cartilage. A histologic and autoradiographic study.

Cortisone leads to damage of the epiphysial cartilage cells of young rabbits, and also of the osteoblasts in the metaphysis, which brings about a change in the appearance of the bone trabeculae in the metaphysis; growth and the faculty of the cartilage cells to produce chondroitin sulphate is reduced, as demonstrated by autoradiography. Combined treatment with vitamin A and cortisone leads to the same changes as cortisone alone. In combination with papain cortisone, during the first few days at any event, does not influence the effect of papain on the cartilage. Prolonged cortisone administration impedes the restitution of the papain-induced changes; the cartilage cells however regain their faculty of chondroitinsulphate synthesis despite the administration of cortisone as shown by autoradiography. Cortison führt bei jungen Kaninchen zu einer Schädigung der Zellen des Epiphysenknorpels und der Osteoblasten in der Metaphyse, so daß die knöchernen Trabekel in der Metaphyse ein verändertes Aussehen zeigen; das Wachstum ist deutlich vermindert, ebenso die Fähigkeit der Knorpelzellen, Chondroitinsulfat zu bilden, wie man autoradiographisch nachweisen kann. Kombinierte Behandlung der Tiere mit Vitamin A und Cortison führt zu denselben Veränderungen wie Cortison allein. Mit Papain kombiniert, beeinflußt Cortison wenigstens während der ersten Tage nicht die Wirkung des Papains auf den Knorpel; längere Cortisonzufuhr hindert die Wiederherstellung nach den durch Papain verursachten Veränderungen. Wie die Autoradiographie zeigt, gewinnen jedoch die Knorpelzellen trotz der Cortisongaben ihre Fähigkeit zurück, Chondroitinsulfat zu synthetisieren.

THE EFFECT OF CRUDE PAPAIN ON THE EPIPHYSIAL CARTILAGE OF LABORATORY ANIMALS

The present investigation has shown that crude papain can be used to produce rapid changes in the epiphysial cartilage of various young laboratory animals (rabbits, mice, rats, guinea pigs and cats).nn1. Single injections of crude papain produce profound changes in the epiphysial cartilage. These changes disappear within a few days. They are radiographically visible as a narrowing of the epiphysial plates. Histologically, the formation of bony trabeculae in the primary spongiosa is found to be arrested.nn2. Repeated injections of crude papain cause permanent damage to the epiphysial cartilage, often with bony closure. Consequently, the longitudinal growth of the injected animals, when compared to the controls, is found to be retarded or permanently arrested, and there may be severe bony deformity.nn3. Using inactivated crystalline papain, we have been able to produce changes in the epiphysial cartilage identical with those caused by the injection of crude papain.nn4. The injection of crude papain is dispelled by the addition of cysteine, but retains its full strength if hydrogen peroxide is added.

Structural changes of the femoral head in cases of non-union of the femoral neck

Our comparative studies of roentgenogram, microradiogram and histology of femoral heads in cases of neck fractures with non-union have shown: Changes of structure of the femoral head can occur in viable bone tissue although they are seldom seen in standard roentgenograms. When such changes are seen they almost always indicate that living tissue has invaded a non-viable head fragment, where bone resorption and new bone formation take place. Sclerosis always means new bone formation There are two types of non-union; with and without structural changes. In cases with structural changes the head fragment is almost always viable. In cases without structural changes the head fragment may or may not be viable and thus roentgenograms do not tell whether the head fragment is viable or not in a case of non-union. Strukturveränderungen des Femurkopfes können in lebensfähigem Knochengewebe auftreten, doch sind sie selten in den gewöhnlichen Röntgenogrammen zu sehen. Wenn man Veränderungen sieht, so weisen sie fast immer darauf hin, daß lebendes Gewebe ein totes Fragment durchsetzt hat. in dem dann Knochenresorption und Knochenneubildung stattfinden; Sklerose bedeutet immer Knochenneubildung. Es gibt zwei Typen der Nichtvereinigung: mit und ohne Strukturveränderungen. In Fällen mit Strukturveränderungen ist das Kopffragment fast immer lebensfähig; in Fällen ohne Strukturveränderungen kann das Kopffragment lebensfähig sein oder nicht, so daß also Röntgenogramme nichts darüber aussagen, ob in Fällen von Nichtvereinigung das Kopffragment lebensfähig ist oder nicht.