E. Burke Evans

Experimental Immobilization and Remobilization of Rat Knee Joints

This is a histological study of rat knee joints that were subjected to limitation of motion alone or were remobilized after varying periods of restricted movement. A progression of morphological changes consequent to restriction of motion was found, and it was possible to gain some indication of the degree of reversibility of these changes after varying periods of immobilization and remobilization either by a single forced manipulation, or by active movement alone, or by repeated gentle passive movement. On the basis of this study, we have arrived at the following conclusions in regard to experimental joint immobilization and remobilization in the rat: 1. Rigid immobilization is not essential to produce structural change, and the maintenance of a slight range of motion will not prevent structural changes; 2. After prolonged immobilization, contracture of both the muscles and the capsule is responsible for restriction of motion, with shortening of the muscles being primarily at fault; 3. Proliferation of intracapsular connective tissue and the formation of adhesions are primary responses to limitation of motion—to a limited degree these changes are reversible; 4. Major cartilage alterations, such as matrix fibrillation, cleft formation and ulceration, as well as their adjacent subchondral lesions, result from abnormal friction and pressure in a joint compromised by limitation of motion—these changes are not reversible; 5. In the rat, the joint changes that are caused by restriction of motion appear to be reversible if the period of immobilization does not exceed thirty days—after sixty days of immobilization all major joint alterations consequent to the restriction of motion have appeared, and further immobilization after this time only causes changes in the degree of these alterations; 6. With forced remobilization there is tearing of the connective tissue that has proliferated within the joint, often in a plane different from that of the original joint cleft; subsequently, associated with continued motion of the joint, a cellular layer with the characteristics of synovial membrane forms about the surfaces of the new cleft; 7. Three methods of remobilization—forced, active, and passive—were used in these experiments, which were equally effective in restoring of the range of motion; after thirty-five days of remobilization by any means the joints were histologically indistinguishable.

Partial and Complete Agenesis or Malformation of the Sacrum With Associated Anomalies: Etiologic and Clinical Study with Special Reference to Heredity A preliminary report

1. Fifty cases of complete or partial agenesis or malformation of the sacrum with associated anomalies have been reported. These include members of the Mexican, Negro, and white population.2. In thirty-two cases reported there is complete absence of the saerum and coccyx, and in eighteen there is pa

The Quality of Life after Major Thermal Injury in Children: An Analysis of 12 Survivors with 80% Total Body, 70% Third-degree Burns

Twenty-one children admitted between December 1981 and May 1985, with greater than 80% total body surface area burn (TBSAB), underwent total excision and grafting of all of their wounds within 72 hours of injury. Twelve survivors (with an average TBSAB of 89%, 82% third degree) were studied in detai

Orthopaedic Measures in the Treatment of Severe Burns

The orthopaedic surgeon, by virtue of his special training, may play an important part in the treatment of severely burned patients. Aspects of treatment which deserve his attention are physical therapy, skeletal suspension, and the design and use of special splints; aspects which require his attention are fractures and dislocations, corrective osteotomies, excision of heterotopic bone, and amputations and prosthetic care. Certain of these aspects are presented in modest detail for the purpose of defining to some extent the role of the orthopaedic surgeon in total care of burns.

Tumoral Calcinosis with Hyperphosphatemia: A Report Of A Family With Incidence In Four Siblings

Four siblings with tumoral calcinosis and hyperphosphatemia have been studied for several years. In one the disease was recognized prior to its clinical appearance because of hyperphosphatemia. The hyperphosphatemia is not a result of renal insufficiency or of an abnormal parathyroid response. The hyperphosphatemia and tumors did not occur independently in our patients, and serum phosphorus determinations may be useful for screening. Recurrence after total excision of a mass is common and should be treated by early re-excision. The initial results of this treatment have been fairly good.

Bone and Joint Changes Following Burns: A Roentgenographic Study—preliminary Report

The skeletal alterations which occur in association with thermal burns have been arbitrarily classified according to their roentgenographic appearance as: osteoporosis, periosteal new-bone formation, pericapsular calcification, osteophyte formation, heterotopic para-articular ossification, joint destruction, and ankylosis. Possible explanations for each of the skeletal changes are offered, but the true pathogenesis is still obscure. Superimposed trauma may be a precipitating factor in instances of heterotopic calcification and ossification and sepsis may be a factor in intra-articular change. Surgical excision of ectopic osseous or calcified tissue is a feasible procedure but should not be undertaken until the patients general condition is good and all scar tissue is mature and soft.

Tumoral calcinosis: A case report and review of the literature

Tumoral calcinosis rarely occurs in the hand. It is an uncommon familial disease suggesting an autosomal recessive gene pattern, often with laboratory findings of hyperphosphatemia and normocalcemia. Our patient had bilateral hand involvement, including local calcinosis cutis of the skin and bone changes not previously reported in the literature. At a 2-year follow-up after two lesions were excised from her left hand, one lesion had completely resolved and the other recurred. Two large symptomatic lesions and one area of local calcinosis cutis in her right hand have recently been excised.

Familial tumoral calcinosis: A forty-year follow-up on one family

BACKGROUND Familial tumoral calcinosis is a rare autosomal recessive disorder that was first described well in a report on four patients from one family in 1969. The disease leads to periarticular ectopic calcifications. The original report described patients from black, healthy, unrelated parents with sixteen children, seven of whom had the disease. METHODS On the basis of retrospective chart reviews and interviews with surviving family members, we describe the long-term follow-up of this one family, encompassing as long as forty years. Of the sixteen siblings, seven had tumoral calcinosis. RESULTS All seven affected children had hyperphosphatemia. There were two subsequent generations comprising thirteen children and seven grandchildren with no instances of tumoral calcinosis. The seven affected patients were followed for as many as forty years and underwent an average of twenty-one operations (range, four to thirty-six operations) for the treatment of calcified lesions. The genetic defect has been identified as the GALNT3 gene, thus leading to the hyperphosphatemic form of the disease. Although two of the patients had died by the time of the present study, the remaining five provided accounts of the disease course, the response to surgery and to medical therapy, and the effect of therapy on their lives. Some members had relatively few lesions and surgical procedures (as few as four), whereas others had an unrelenting course of lesions, recurrences, and surgical procedures (as many as thirty-six, with numerous other procedures). Three patients had multiyear periods with few symptoms--one for seven years, one for twelve years, and one for fifteen years. No effective medical therapy was found to control the lesions, and operations were associated with a high recurrence rate. CONCLUSIONS Familial tumoral calcinosis has a varied natural history; some patients have an unrelenting course, while others may experience quiescent periods. The GALNT3 gene is responsible for the hyperphosphatemic form as seen in this family. Molecular testing may be of benefit to members of affected families, and future studies may help to explain the phenotypic variability among affected individuals. No medical or surgical treatment plan seemed to be effective for controlling the lesions in this family.

Metacarpophalangeal-Joint Dislocations of the Fingers

1. Four cases of metacarpophalangeal dislocations of the fingers are presented. 2. The trapping elements of the little-finger dislocation are described. 3. With the techique described, open reduction is easy and the reduction is stable and does not require transfixation of the joint. 4. Dislocations of the fifth metacarpophalangeal joint, which cannot be reduced by closed means, can be reduced by open means by a volar approach that avoids blind transection of the fibrocartilaginous plate.

Valgus slipped capital femoral epiphysis.

Abnormally high stresses involving the capital femoral physis were found in a series of valgus slipped capital femoral epiphysis cases. Using a single leg stance model we studied 10 hips in seven patients in which the epiphysis was lateral and posterior in relation to the femoral neck and calculated that shear stresses were high enough to be associated with failure of the physis. Valgus neck shaft angles and lateral tilt of the physes were seen in all cases.