Crawford J. Campbell

Giant-cell tumor of bone. An analysis of two hundred and eighteen cases.

Two hundred and twenty-two tumors in 218 patients were collected from different institutions and doctors. Eight patients had died less than eighteen months after the diagnosis was made, one of an unrelated disease, the others as a result of their tumor. The remaining 210 patients with 214 tumors were followed for an average of 9.9 years, the range being two to thirty-four years. In each case, skeletal maturity, location of the lesion, roentgenographic findings, histological characteristics, and treatment were analyzed. Skeletal maturity, as evidenced by closure of the epiphyses, was present in all patients. This observation may explain the predominance of females (27:11) in the patients less than twenty years old. More than half (55 per cent) of the lesions were located in the lower end of the femur, the upper part of the tibia, and the lower end of the radius. Other sites were the sacrum, pelvis, proximal end of the femur and fibula, and the small bones of the hands and feet. The roentgenographic findings were sufficiently characteristic to be helpful but not diagnostic. They were influenced by previous treatment of fracture. The histological features permitted grading as suggested by Jaffe, Lichtenstein, and Portis30. However, the grading was not of prognostic value although it did serve to alert the surgeon to the possibility that the tumor was malignant. A consistently accurate prediction as to local recurrence or pulmonary metastasis could not be made on the basis of the histological grade. The treatment of the tumors in this series was performed by many surgeons and varied considerably. All patients had a preliminary biopsy. The primary surgical treatment ranged from curettage or excision, with or without bone-grafting, to amputation. The success of surgical treatment, whether by curettage or resection, appeared to depend on the completeness with which the tumor was removed. After primary curettage, thirty-five of forty-five tumors recurred; whereas, after primary curettage combined with bone-grafting, twenty-two of the ninety-one tumors recurred. After primary resection, ten of the forty-four tumors recurred, whereas, after primary resection combined with bone-grafting, four of twenty-two tumors recurred. Primary amputation was performed for ten tumors none of which recurred. After primary irradiation, six of ten tumors recurred. Ninety-seven per cent of the recurrences occurred within two years of the time that the initial diagnosis was made. At the time of this study, 189 of the 218 patients were alive and well, and twenty-nine had died. Of the 189 who were alive and well, 121 had had no recurrence after primary treatment and sixty-eight had required secondary procedures. Of the twenty-nine patients who had died, fourteen had died of their tumor, three of postirradiation sarcoma, and twelve of unrelated disease. Eighteen of the twenty-nine dead patients had recurrent lesions. In the whole series, 180 secondary procedures were performed, 140 on sixty-eight patients who survived and forty on the twenty-nine patients who died. Of the 140 procedures on surviving patients, eighteen were for infection, five for lung metastases, four for fracture or non-union of a bone graft, and 113 for fifty-nine recurrences. The forty procedures done on the patients who died included one for infection, one for fracture of the bone graft, two for lung metastases, and thirty-six for recurrences. Of the seventy-seven patients who had recurrent lesions, fifty-six had one recurrence; sixteen, two recurrences; and four, three recurrences. Success in the treatment of recurrences was observed after a second curettage with or without bone-grafting in nine of sixteen patients, after secondary resection with or without bone-grafting in sixteen of thirty-five patients, after secondary irradiation in five of thirty-six patients, and after amputation in thirty-nine of forty-six patients. Irradiation, used for ten primary and thirty-six secondary tumors, was clearly beneficial in eight, possibly helpful in nine, and clearly ineffective in twenty-nine. Three of the patients so treated had postirradiation sarcoma. The average follow-up of patients who had radiotherapy was 9.2 years (the range four months to thirty-four years). In five of the six patients with pulmonary metastases, lobectomy was successful.

Melorheostosis: A Report Of The Clinical, Roentgenographic, And Pathological Findings In Fourteen Cases

1. Fourteen previously unreported cases of melorheostosis are presented. The disease progressed rapidly in the children and slowly in the adults. Contracture and deformity were the earliest findings in childhood and pain and stiffness in affected joints was the most common complaint in adult life. Soft-tissue contractures and deformities, especially in the hands and feet, were usually found and treated before roentgenograms were made which showed the characteristic hyperostosis. 2. Roentgenograms made in infancy or early childhood usually showed a faint linear hyperostosis which was difficult to diagnose. This rapidly increased in the immature skeleton and more slowly in the adult skeleton, eventually producing the appearance of bone flowing along the cortex. 3. Abnormality of the soft tissues of mesodermal origin, as manifested by contractures, was usually discovered earlier than the underlying hyperostosis, often leading to incorrect diagnoses. They usually caused greater deformity and disability than the disease in bone. 4. The pattern of involvement suggests that this disorder is a congenital abnormality akin to paraxial hemimelia and that it is initiated early in embryonic life prior to the formation of the limb buds.

The Effects Produced in the Cartilaginous Epiphyseal Plate of Immature Dogs by Experimental Surgical Traumata

quent experimenters demonstrated time existence of this growth by placing markers in time bone 4,11,17,22.30.50,61.68, by feeding madder which is selectively fixed in timose portions of the skeleton wimicim are growing 2,29,35,40,51 and by following the course of time lines of growth arrest 5,7,8,12,18,39,52,59,05#{149} Time microscopic anatomy of the epiphyseal plate was first described in 1858 by Muller and clarified by Fell, Ham, Streeter, and others 10,42,46,47 Starting at the epiphyseal margin of time plate, these investigators described zones of resting cartilage, proliferating cartilage, maturing and hypertrophic cartilage, and calcified cartilage. Leser, Retzius, and others 11,42,54,63 believed that time interstitia! growth of time epiphyseal plate was caused by increase in the size of mdividual cartilage cells as timey mature, and by active proliferation of the cartilage cells in time zones of the plate nearest time epiphysis wimere time existence of mitoses was noted. Some clinical and experimental findings nmigimt seem to indicate timat part of time growtim in lengtim of a long bone or a bone graft is due to interstitial growth within the bone itself. An increase in the lengtim of the mass of a spine fusion has been noted in inmnmature animals 441 and in children 26,45,56 Odelberg-Johnson and Lacroix imave attempted to explain timis apparent increase in length on time basis of small infractions witim subsequent healing. Selye and Hehlstadius, in experimental studies on very young animals, interpreted new-bone formation at the distal tip of time femur after extirpation of the epiphysis as intrinsic growth of time bone, althougim their illustrations suggest ectopic-bone formation. Despite these opinions to the contrary, the weight of experimental evidence supports the basic concept that interstitial growth of cartilage witimin the epiphyseal plates accounts for the growtim force wimicim causes time elongation of growing long bones. The effects of injury to time epipimyseal plate caused by surgically produced defects or incisions have been observed clinically and in experimental investigations. Oilier, in 1867, simowed timat superficial linear incisions across time epipimyscal plates in rabbits and cats often caused no disturbance of growtim, wimereas deep incisions caused retardation. Similarly, multiple punctures of time plate using needles did not affect growtlm. Vogt, in 1873, did not find any retardation of growth if epipimyseal separation was produced through time natural line of cleavage in time epipimyseal plates of goats and simeep except when the epi )imySis was deeply lacerated at the time of separation. Jahn, in 1892, noted that in rabbits, * Read at the Annual Meeting of The American Orthopaedic Association, Lake Placid, New York, June 16, 1959. t This investigation was supported by The William Austin Fund for Orthopaedic Research of the Albany Medical College and the Orthopaedic Researcim and Education Foundation, Inc.

Dysplasia Epiphysealis Hemimelica: A Report Of Fifteen Cases And A Review Of The Literature

Fifteen new cases of dysplasia epiphysealis hemimelica are reported and the literature is reviewed. The cartilage overgrowth was usually found to be limited to one extremity and to half of the affected epiphysis. The microscopic pathological changes are indistinguishable from those of an osteocartilaginous exostosis. Excision of the lesion is indicated when it produces deformity or interferes with function. Other procedures are seldom required. These lesions retain the potential for cartilage proliferation in adult life and, we presume, for malignant degeneration. They should be closely followed in the adult and be removed if they increase in size.

THE TRANSPLANTATION OF ARTICULAR CARTILAGE. AN EXPERIMENTAL STUDY IN DOGS.

1. Transplants of articular cartilage with a thin adjoining osseous border were inserted anatomically in the knee and wrist joints of forty-two adult mongrel dogs and studied histologically at intervals ranging from five to 500 days. 2. Autogenous transplants of large articular fragments and half joints were often successful. 3. Homogenous transplants of large articular fragments and half joints, not at first, but eventually, showed degenerative changes and disintegration when subjected to weight-bearing function. 4. Within the degenerated homograft, articular cartilage foci persisted and remained viable for more than one year. 5. Both autogenous and homogenous transplants of cartilage into muscle showed gradual degenerative changes and absorption.

Squamous-Cell Carcinoma of the Nail Bed in Epidermal Dysplasia

A case of epidermal dysplasia is reported which squamous-cell carcinomata developed in the nail beds of two fingers. Three fingers in this case were analyzed pathologically and compared with three fingers of a normal man of the same age. In epidermal dysplasia there was irregularity of all strata of the nail bed and a low-grade inflammatory reaction in the corium. It is our impression that the irregularity of growth in epidermal dysplasia could in itself be a precursor to the development of squamous-cell carcinoma.

Intracapsular or Para-articular Chondroma: A Report Of Three Cases

Intracapsular or para-articular chondromata usually occur at the knee where they are infrapatellar, extrasynovial, and deep to the patellar tendon. The presenting complaint is a mass and aching. Restricted motion is uncommon. There is no sex predilection. All patients were over twenty and were frequently in the fourth and fifth decade. The roentgenograms may be normal, show spotty areas of calcification, or demonstrate a lobulated oval osseous mass. The microscopic appearance varies with the stage of the lesion. Early, there is cartilage metaplasia and proliferation. This is followed by cartilage degeneration and calcification. With the ingrowth of vessels enchondral ossification occurs and may progress to complete bone replacement. The treatment is excision. Recurrence, as seen with synovial chondromatosis, and malignant degeneration have not been reported. These lesions must be differentiated from synovial chondromatosis and chondrosarcoma.

Experimental study of the fate of bone grafts.

In this experiment, 141 split-rib grafts implanted into mature dogs showed the following: 1. All grafts were successfully transplanted in that they were incorporated into the host osteogenic bed. 2. Histological examination revealed osteogenic cells and osteocytes to survive only in fresh autogenous bone grafts. This osteogenetic activity was found to take part in the incorporation of the graft into the host tissue. 3. Fresh autogenous bone grafts were more readily tolerated by the host tissue than the preserved bone grafts or fresh homogenous grafts.

Analysis of the intraosseous stress field due to compression plating

Abstract Photoelastic methods, strain gages, and other techniques using plastic models and bone samples, with several available compression plates, are used in an attempt to establish a model for the determination of the intraosseous stress field created in a fractured long bone due to the installation of a compression plate. Analysis of this model shows that a superposition of compression and bending induced in the bone causes compaction of the bone ends over a small area of contact directly under the plate, and distraction of the bone ends away from the plate. It is found that at an axial load, in the plate, of 120 lb f (534 N), a bending moment of about 90 in-lb f (10 m-N) is applied to the bone. This results in a contact area of from 8 to 20 per cent of the area of the bone ends, on which the stress may be as high as 8400 psi (5·8 × 10 − N/m 2 ). No attempt is made to examine the biological effects of compression plates on fracture healing.