Fred C. Reynolds

The non-operative treatment of collateral ligament injuries of the knee in professional football players. An analysis of seventy-four injuries treated non-operatively and twenty-four injuries treated surgically.

Seventy-four ligamentous injuries of the knee in professional football players were managed without surgery during thirteen seasons of play. A success rate of 98 per cent in this group was contrasted to a success rate of 74 per cent in twenty-four patients treated with surgery in the same period. The criteria for patient selection included stability of the knee, absence of bone injury, and progressive improvement during conservative therapy. The treatment regimen avoided the use of casts and emphasized motion and exercises.

Variations in Normal Bone-Marrow Pressures

1. In the same bone, and under similar physiological conditions, the mean systolic marrow pressure in the diaphysis is significantly higher than the mean systolic marrow pressure in the epiphysis. 2. In the same bone, and under similar physiological conditions, the pulse pressure the diaphysis is significantly greater than the pulse pressure in the epiphysis. 3. There is a rhythmical fluctuation in the marrow pressure in the diaphysis and epiphysis which is synchronous with the phases of respiration. The fluctuations are most pronounced during forceful expiration.

The acute effects of periosteal stripping and medullary reaming on regional bone blood flow.

The immediate effects of surgical dissection on regional bone blood flow were studied using the hydrogen washout technique and the results were compared in mature and immature rabbits. Epiphyseal circulation in young animals was eliminated by stripping the epiphyseal periosteum, and even in mature rabbits epiphyseal blood flow was markedly reduced by periosteal stripping. This suggests that after skeletal maturity blood supply crossing from the metaphysis into the epiphysis is limited. The blood flow rate was not altered by wide reaming of the epiphyseal center in either young or old animals. The rates of bone blood flow in the metaphysis and diaphysis were not altered by separate periosteal stripping or medullary reaming in either age group. Combined reaming and stripping eliminated blood flow in the diaphyseal cortical bone, but in the metaphysis fairly rapid blood flow remained even after reaming and periosteal stripping were done. These findings suggest that arterial supply and venous drainage traverse both endosteal and periosteal surfaces, and either system is capable of sustaining adequate bone tissue circulation.

Tibiofibular synostosis and recurrent ankle sprains in high performance athletes

Recent evidence points toward a weight bearing and dynamic stabilizing function of the distal fibula in ankle joint mechanics. When fibular rotation and translation are restricted, ankle pain during weight bearing and push off often (but not always) results. The case histories of six professional athletes with distal tibial synostosis resulting from internal rotation-inversion injury confirm recent reports of ankle disability resulting from restriction of fibular motion, but suggest that there may be many patients with this lesion who are not disabled. Two patients with incomplete synostosis were asymptomatic, and one with complete synostosis had only occasional pain after vigorous exercise.

EXPERIMENTAL EVALUATION OF HOMOGENOUS BONE GRAFTS

1. There is no evidence from these experiments that any of the bone elements of an autogenous transplant live or retain osteogenetic powers. 2. The authors have demonstrated that, with the inlay type of graft, the fixation and replacement of the graft was totally a function of the host tissue. 3. The fixation and replacement of both autogenous and homogenous bone grafts was accomplished in an identical fashion by appositional growth of the host bone. Socalled creeping substitution was but a localized phase in the process of appositional bone growth. 4. Autogenous bone grafts were superior to homogenous bone grafts experimentally only in that the early phase of healing was slightly more rapid and uniform. However, this was not due to viability and regrowth of autogenous grafts; rather it probably represented less host reaction and tissue specificity, which are factors not understood at present. 5. At the end of ten weeks, no microscopic difference could be seen between the autogenous and homogenous grafts; practically complete replacement was present in both. 6. Merthiolate-preserved bone and frozen homogenouts bone were indistinguishable experimentally. Boiled homogenous bone, however, proceeded to union much more slowly. 7. The clinical use of homogenous bone grafts is justifiable.

Clinical evaluation of the merthiolate bone bank and homogenous bone grafts.

The authors remain convinced that process of fixation and replacement is accomplished in a similar manner in autogenous and homogenous bone grafts, but we are not at all sure that the differences in time of union and the number of failures can be explained entirely on the basis of tissue specificity. There is reason to believe that some of the cells of an autogenous graft are capable of survival and of instigating this process and thus accelerating it when host capillaries reach the graft. This could account both for the more rapid union of the autogenous graft as compared with homogenous graft and for the greater number of successes with autogenous grafts. Merthiolate-preserved bone does not compare favorably with autogenous bone grafts in that the process of fixation and replacement is definitely retarded, requiring prolonged protection with a higher percentage of failures (30.24 per cent. in this series). The merthiolate bone bank is a very satisfactory method of preserving bone. We have no evidence of sensitivity to the merthiolate or excess tissue reaction to merthiolate preserved bone. The method is certainly easier and more economical of bone than the frozen bone back. A homogenous bone graft which is adequately placed in a good bed and protected for a sufficiently long time may be expected to unite. Many of the failures listed above should not be ascribed to the bone bank or to homogenous bone grafts but to poor surgery. Still others can be attributed to the injudicious use of bone grafts; in these cases failure would probably have occurred irrespective of whether a homogenous or an autogenous graft was used. However, we have modified our original expectations of preserved homogenous bone graft and now feel that these grafts should be considered as useful aids in orthopaedic surgery rather than as universal substitutes for autogenous bone. Obliteration of cavities in bone created by sequestrectomy and saucerization for osteomyelitis, or local excision of benign tumors by homogenous bone from the bank, has given good results. Where the defect is large, bank bone is preferable to autogenous bone because of the great amount required. Homogenous peg or inlay grafts have Proved satisfactory in the treatment of minor non-unions. Likewise, bank bone has been very useful for internal splinting in arthrodesis and for treating certain fresh fractures. However, homogenous bone grafts should never be used in the treatment of major non-unions if there is any possibility of using an autogenous graft. It is our feeling that the use of bank bone should be reserved for those circumstances in which it is not feasible or advisable to use autogenous bone. These are: 1. When the available supply of autogenous bone does not fulfill the particular requirements; 2. When the taking of an autogenous bone graft will materially increase the hazard of the operative procedure: 3. In any condition where there is a chance that the graft will be lost because of infection; 4. During the course of an operation when it is decided that a bone graft would be useful and when no previous Plans for taking a graft had been made; 5. In those cases where the bank bone is used as an internal splint when the condition would not justify the taking of an autogenous graft.

Hemangiopericytoma of the Lower Extremity

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Management of chronic osteomyelitis secondary to compound fractures.

The authors feel that the management. of osteomyelitis secondary to infected compound fractures should consist in debridement and saucerization, with closure of the wound by primary suture, if it can be done without excessive tension. Otherwise, the method of delayed closure by split-thickness skin grafts should be used. After healing of the infection, union will occur in many cases of previous non-union. Many patients need no further surgery after wound healing because of adequate remaining bone, and because the bone and skin pockets are small. With non-union, large bone defects, or large bone and skin pockets, and in those cases in which reinforcement is required for stability, three months should elapse after complete healing of the wound before bone-grafting is done. The use of cancellous bone, from which as much cortex as possible has been removed, is recommended. If the defect is large, it may be difficult to obtain sufficient bone without the use of cortical chips. The authors have had no experience with bone grafts at the time of debridement and saucerization, but this seems to be the next step in evaluating the management of chronic osteomyelitis. Careful preoperative and postoperative preparation with antibiotics and blood transfusions is essential. As postoperative drainage appeared to result from hematoma, which was prone to become infected, it is suggested that delayed primary closure of the wounds would give a higher percentage of complete early healing. The authors see no reason why chronic osteomyelitis of hematogenous origin could not be managed in a similar way.

Surgery in the treatment of low-back pain and sciatica; a follow-up study.

We have submitted the records of 115 patients operated upon for intervertebral-disc lesion to a rather searching analysis. The results in these patients have been classified according to arbitrarily established criteria and as many variables as possible were eliminated from the study. In addition, the figures were all submitted to statistical analysis. Significant findings are: 1. Patients with good historical, physical, and myelographic evidence of nerve-root compression obtain better results from disc surgery. 2. Patients who, at operation, are found to have completely extruded discs obtain better results. 3. In this series, the results in women are not significantly worse than in men. 4. In women, the majority of disc lesions are located at the fourth lumbar interspace. Many of these were also associated with degenerative discs at the fifth lumbar interspace. 5. In men, there appears to be no such predilection for any given interspace. 6. Fourteen (12 per cent) of the patients had recurrence; ten of these were on the same side as the original lesion, and four were on the opposite side. 7. Twenty-eight patients (24.3 per cent) probably should not have had an operation performed. It seems clear that if we remember the past history of low-back pain and sciatica and if we understand the pathological changes in the disc with the resulting altered function of the disc unit, we will limit surgery to those who continue to be disabled as a result of pain, or have progressive neurological alteration in spite of adequate conservative therapy. At the present time, it is our opinion that where conservative treatment fails and after careful study exploration reveals only a degenerated disc, spine fusion should be done. In those cases in which the operative finding is one of definite nerve-root compression, simple disc excision seems adequate. When the original operation fails or the patient has recurrence, fusion should be a part of the secondary operative procedure.

Preliminary Report of the Committee on Fractures and Traumatic Surgery on the Use of a Prosthesis in the Treatment of Fresh Fractures of the Neck of the Femur

This review suggests that the insertion of a prosthesis in the treatment of fresh femoral-neck fractures is not appreciably more hazardous to the patient than internal fixation. In carefully selected patients it allows more rapid ambulation and a shorter period of hospitalization and postoperative disability. Concerning the type of prosthesis, although results with the various models are not greatly dissimilar, there is evidence that the metallic long-stem variety is best. I had expected the anterior type of operative procedure to be much superior; however, there was little difference between the two. The percentage of satisfactory results was greater in patients in whom the posterior approach was used ; but there were fewer complications, a shorter period of hospitalization, and fewer deaths in the first thirty days with the anterior approach. Repair of the capsule, when possible, is advisable. Although the figures do not show striking differences, there is an indication that the avoidance of postoperative fixation, in addition to early ambulation, results in fewer complications. The use of a prosthesis may be indicated purely for relief of pains in the severely debilitated patient; for the most part, however, to justify an operation of this magnitude, one prerequisite should be a reasonable chance that the patient may soon again become ambulatory. There does seem to be a place for the replacement prosthesis in the management of fresh femoral-neck fractures. Since the length of time a prosthesis may be expected to function cannot be determined by this study, we feel that the circumstances in which this procedure is presently indicated are as follows: 1. In the old patient who is a relatively poor risk and in whom it seems likely that only one surgical procedure will be possible. 2. When early ambulation is essential and the condition of the patient makes the use of a walker or crutches unlikely. 3. In patients who have Parkinsons disease or spastic paralysis. 4. When a satisfactory reduction and fixation of the fracture cannot be obtained even by open operation.