Clinton L. Compere

A new method of patellectomy for patellofemoral arthritis.

Total patellectomy, although it has a biomechanical disadvantage in that it may lead to a degree of quadriceps weakness, is frequently indicated in selected patients. Numerous different techniques of performing patellectomy have been described. In this paper, we present a technique of performing a patellectomy in which the continuity of the quadriceps mechanism is not disrupted and the vastuc medialis is advanced. Twenty-six patients (twenty-nine knees) in whom the procedure was performed were studied retrospectively. The findings in this series showed 90 per cent good or excellent results, two cases of extensor lag, an average of 118 degrees of knee flexion, minimum quadriceps atrophy with good strength, and minimum postoperative immobilization. The method presented has the important advantage of an easier, smoother postoperative knee-rehabilitation period, which is extremely advantageous in elderly patients.

The number of total joint replacements in the United States.

By comparing estimates from several sources an assessment can be made of the number of total joint replacement procedures performed annually in the United States. Approximately 80,000 hips and 40,000 knee joints were replaced in the U.S. during 1976. Total hip replacement has been accepted by the orthopedic community as an efficacious mode of treatment of the many painful and disabling forms of arthritis. A substantial patient population could benefit from perfection of designs for treating joints other than the hip.

CORRECTION OF DEFORMITY AND PREVENTION OF ASEPTIC NECROSIS IN LATE CASES OF SLIPPED FEMORAL EPIPHYSIS

1. The object of treatment of slipped or slipping capital femoral epiphsysis is to maintain or restore painless hip function, with a range of motiots as nearly normal as possible and a minimum of shortening of the extremity. 2. Epiphysiolysis with marked displacement has been treated by open wedge osteotomy with uniformly good results. Aseptic necrosis with osteo-arthritis occurs rarely. The incidence is definitely less than that which follows closed manipulation, and is no greater than that which follows application of a cast without any attempt at reduction. 3. An accurate determination of the degree of slipping is essential. This is possible only with good lateral roentgenograms of the hip. 4. To avoid aseptic necrosis or delayed osteo-arthritis, there must be a minimal amount of damage to the blood supply when the capsule is opened to expose the joint. 5. Wedge resection of the proximal superior portion of the femoral neck should he followed by gentle freeing of the head, just distal to the epiphyseal line. 6. The epiphsyseal plate must be perforated with a gouge and a curette, thus exposing porous cancellous hone on the portion of the head which will be in contact with the prepared neck surface. 7. Great care should be exercised in the reduction to prevent additional injury to the cir(culation of the femoral head, as a result. of needless stretching or tearing of the ligamentum teres or the capsular vessels. The head should be placed in position over the raw bone surface on the top of the neck. 8. Rigid intetnal fixation of the head of the femur to the neck is essential. 9. Early active motion is most desirable, with the hip Protected from weight-bearing until healing is complete. 10. If the follow-up roentgenograms show aseptic necrosis, weight-bearing should be postponed until there is roentgenographic evidence of replacement of the dead bone by creeping substitution.

Hypophosphatemic vitamin D refractory osteomalacia with bilateral femoral pseudofractures.

The case of a young adult female who developed multiple orthopedic problems associated with genetic osteomalacia is presented. Pathologically in the subcapital regions of both proximal femurs severe osteomalacic callus through stress fractures was demonstrated.

Amputation and Rehabilitation for Severe Foot Ischemia

Definitive amputation for foot ischemia secondary to arteriosclerosis with or without diabetes, should always be considered an important first step in the process of rehabilitation. If the patient can have a below-knee amputation, the end product is a great deal more satisfactory than if the patient has an above-knee amputation. Ultimate ambulatory status can be achieved only by preserving both knee joints.

Possible Etiologic Factors in the Production of Pulmonary Osteoarthropathy.

Periosteal new bone formation secondary to intrathoracic lesions such as pneumonia, empyema, bronchogenic carcinoma or tuberculosis, spoken of as pulmonary osteoarthropathy or generalized osteophytosis, 1 is a well recognized clinical entity. Theories of the factors responsible for the new bone formation have varied from that of toxic absorption from focal infections in the chest 2 to changes in the acid-base equilibrium through decreased aeration as a result of constriction of the bronchi or of lung compression and collapse. To explain the etiologic factor responsible for these peripheral bone changes, we have attempted to produce them in experimental animals. Before and after creating intrathoracic complications in dogs, roentgenograms were made of the long bones of the lower extremities and the calcium and phosphorus and carbon dioxide content and H ion concentration of the blood serum were determined. These studies were repeated at varying intervals and no significant changes in the blood chemistry were found. Of 9 dogs, into whose right pleural cavity from 100 to 300 cc. of parafin were injected, one survived 9 months and 2 are still alive after a period of nearly 18 months. In each instance, in addition to the mechanical pressure on the lung by the parafin, there was a prompt pleural effusion which almost completely displaced air-containing tissue on the right half of the chest. No periosteal reaction or new bone formation along the shafts of the long bones could be demonstrated in any of these dogs although frequent x-ray examinations were made. Blood chemistry studies were made at frequent intervals. No consistent or significant blood changes were noted following the injection of the parafin. Using a method described by one of us 3 collapse of one or more lobes of the lungs of 13 dogs was accomplished.

Intervertebral disc removal and spine fusion

Abstract We have concluded that a spine fusion procedure should be performed upon all patients from whom a ruptured or herniated intervertebral disc is removed. Most patients with simple disc excision will undergo subsequent degenerative changes in the facet joints of the lumbar spine. We have been unable to arrive at any reliable criteria for differentiating among those patients who will not need spine stabilization and those in whom back pain will be so incapacitating that a second operation for spine stabilization should be performed. One hundred fifty-four of our patients with herniated intervertebral disc lesions requiring surgical intervention were reviewed, and in 120 patients the end results were studied. Of this group of 120, 44.1 per cent had excellent results, 26.6 per cent had good results, 17.5 per cent were satisfactory, and 11.8 per cent poor. The number of patients complaining of any residual back pain in the entire group was 17 per cent. In our cases an added spine stabilization procedure has not shown any increased incidence of morbidity as compared to the simple procedures. The patients averaged 18.4 days in the hospital, which is not a marked increase over those in whom only a simple disc excision is performed. In most patients the length of time away from productive employment is also not materially lengthened over that when only the simple procedure is performed. The results are far from perfect, but with increased attention to the finer details of spine fusion technic they can be improved. Although some of our patients exhibit a pseudarthrosis, these spines are remarkably stable due to dense fibrous tissue formation resulting in a decrease in back pain. Surgeons who evaluate end results on a basis of relief of sciatica alone tend to ignore a major disability factor. Backache is the cause of more chronic disability than nerve pain from sciatica. No end result study can be accepted unless it is based on an evaluation at least four to five years after surgery. Patients who have had a disc removed and later require a fusion dread the second operation much more than the first, and all degrees of anxiety and psychoneurosis are seen in these patients. Pantopaque, although believed to be rapidly absorbed in the subarachnoid space, was found to be present in significant amounts as long as ten years after myelography. However, no significant reactions were noted to the prolonged presence of the pantopaque media.

Modern amputation technics.

Northwestern University is one of three university centers participating in a coordinated program of research and education directed toward solving the complex problems of amputees. Major improvements in artificial limbs have been made in recent years. Some of the modern devices are illustrated. A physician who accepts an amputee or a potential amputee for a patient assumes responsibility for maximal restoration, including participation in prescription of a prosthesis and supervision of training. The amputee is permanently in need of qualified medical supervision.