Hugh G. Watts

Current Concepts Review - Tuberculosis of Bones and Joints*

The prevalence of tuberculosis15 in the United States has been rising since 1986, with morbidity increasing 14 per cent from 1985 through 1993. In 1986, the rate of tuberculosis in the United States was 9.3 new cases per 100,000 population. In 1991, the rate in New York State12,13 had risen to 17.3 per 100,000, and the rate in central Harlem was 169 per 100,000, which is similar to rates reported in the eastern and central regions of Africa7,12. Much of this increase has been in the rate of pulmonary tuberculosis, but it has been associated with a concomitant rise in the number of adults and children who have tubercular musculoskeletal involvement. In a prospective study of a cohort of intravenous drug abusers in New York City who tested positive with the tuberculin skin test, the risk of active tuberculosis was 14 per cent (seven of forty-nine patients) a year during a two-year follow-up interval76. It is becoming increasingly likely that an orthopaedic surgeon who works in a developed region of the world (especially in a big city) will encounter a patient who has tuberculosis, a disease with which the surgeon may have little experience or training13. Factors that have contributed to the increased rate of tuberculosis are the rise in the number of people who have suppression of the immune system, the development of drug-resistant strains of Mycobacterium, an aging population, and an increase in the number of health-care workers who are exposed to the disease. The human immunodeficiency virus remains the leading known risk factor for the reactivation of latent tuberculous infection65,68,79, and patients with this virus who are exposed to Mycobacterium tuberculosum are more likely to have progression to an …

Concomitant Presence of Tumor-Specific Cytotoxic and Inhibitor Lymphocytes in Patients with Osteogenic Sarcoma

The lack of detectable tumor-specific cytotoxicity by the peripheral blood lymphocytes of patients with cancer may be due to a lack of cytotoxic lymphocytes or the presence of suppressor lymphocytes that inhibit cytotoxic cells. Unfractionated peripheral blood lymphocytes from 12 of 28 patients with osteogenic sarcoma were cytotoxic to osteogenic sarcoma cells in vitro (P less than 0,001). When the peripheral blood lymphocytes from patients whose lymphocytes were not cytotoxic underwent fractionation, a tumor-specific cytotoxic subpopulation was isolated from 11 of 13 patients (P less than 0.0001). Lymphocytes that inhibited cytotoxic activity of autologous tumor-specific cytotoxic lymphocytes were found in four of 10 patients with osteogenic sarcoma but not in six normal controls. Inhibitor lymphocytes form rosettes with sheep erythrocytes and adhere to nylon, whereas cytotoxic lymphocytes have a receptor for C3 but no surface immunoglobulin. The lack of tumor-specific lymphocytotoxicity in some patients can be due to inhibitor lymphocytes.

WEEKLY HIGH-DOSE METHOTREXATE-CITROVORUM FACTOR IN OSTEOGENIC SARCOMA Pre-Surgical Treatment of Primary Tumor and of Overt Pulmonary Metastases

Vincristine‐high‐dose methotrexate‐citrovorum factor (VCR‐MTX‐CF) was administered preoperatively at weekly intervals to eight patients, four with primary tumors and four with pulmonary metastases. These patients had not received prior VCR‐MTX‐CF treatment. A similar treatment program was administered to five patients with pulmonary metastases who had received prior VCR‐MTX‐CF. Among the eight patients who had not received prior VCR‐MTX‐CF, complete responses were obtained in three with primary tumors (this was followed by surigical excision) and two with pulmonary metastases. Partial responses occurred in two additional patients. Partial responses were also obtained in two patients who had received VCR‐MTX‐CF. Chemotherapy and surgery in one patient with an extremity lesion resulted in preservation of the limb and useful function. The major toxicity was anorexia and weight loss. Other side effects included stomatitis, myelosuppression, hepatitis and transient renal impairment. The weekly program was highly effective when compared to responses obtained with the tri‐weekly schedule utilized in previous studies.

Diagnostic modalities for the evaluation of pediatric back pain: a prospective study.

The commonly taught premise that pediatric back pain frequently has an underlying diagnosis has been recently challenged. Previous studies have suggested that up to 84% of children with low back pain have associated serious diagnoses. Children with back pain, therefore, have frequently undergone exhaustive diagnostic testing. There have been few prospective studies, however, about the diagnosis rate and appropriate diagnostic methods for back pain in children. This study prospectively examines the rate of diagnosis for pediatric back pain and the value of various diagnostic studies for this problem. Methods: All patients presenting to our institution with a chief complaint of back pain were evaluated for the study. Inclusion criteria consisted of age younger than 18 years, no previous back surgery, no previous diagnosis given, and duration of pain longer than 3 months. Seventy-three patients were enrolled in the study, and an algorithm was created for diagnostic evaluation. The algorithm incorporated commonly used diagnostic techniques including radiographs, magnetic resonance imaging, computed tomography, bone scan, and laboratory studies. The end point was considered to be either (1) a definitive diagnosis or (2) no diagnosis and no symptomatic or clinical changes during a 2-year period. Results: Fifty-seven patients (78.1%) ended with no diagnosis. Of the remaining 16, 9 were diagnosed with spondylolysis with or without spondylolisthesis. Three other patients had abnormal laboratory values but no definitive diagnosis. Other diagnoses included Scheuermann disease (n = 2), osteoid osteoma (n = 1), and a herniated disk (n = 1). Conclusions: This investigation is the largest prospective study of diagnostic modalities in pediatric back pain to date. Contrary to most of the previously published data, most of our patients ended the study with no definitive diagnosis. In addition, the most of the diagnoses were made at initial physical examination or via initial plain radiographs. No diagnoses were missed using our algorithm. These results suggest that pediatric back pain frequently does not carry a definitive diagnosis and that exhaustive diagnostic protocols may not be necessary for this problem. Level of Evidence: Prospective study; Level 2 clinical evidence.

The Boston brace system for the treatment of low thoracic and lumbar scoliosis by the use of a girdle without superstructure.

A brace for the non-operative treatment of scoliosis constructed without a metal superstructure is preferred by teenage patients. Preliminary results show that a 50-60% correction can be achieved as measured on standing X-rays in the brace. Three quarters of these patients have no skin problems associated with brace wearing. In several years when these patients have reached skeletal maturity and have spent 1 year out of their braces, it will be possible to determine whether the short term results are comparable to the standard set by the Milwaukee Brace.

Distal femoral extension osteotomy for knee flexion contracture in patients with arthrogryposis

Severe knee flexion contractures in patients with arthrogryposis multiplex congenita were treated by distal femoral extension osteotomy. Thirty-two operations were followed for an average of 32 months. Contractures were corrected from 49 degrees to 6 degrees. During follow-up there was a loss of correction of 22 degrees at a rate of 0.9 degrees/ month. The angle of the distal femoral physis and the shaft of the femur was 2 degrees of flexion preoperatively, and postoperatively it measured 43 degrees of extension and at late follow-up it measured 19 degrees. Remodeling occurred at a rate of 1.0 degrees/month, which correlated with recurrence. All patients increased their ambulatory ability at least one level. There was one wound infection. Distal femoral extension osteotomy is effective and safe for the correction of knee flexion contracture. Recurrence occurs in all growing children.

The Ilizarov method for the treatment of resistant clubfoot: is it an effective solution?

Abstract: The resistant clubfoot deformity presents a significant challenge. Several corrective procedures have been described, with the goal to provide a pain-free, plantigrade foot. The Ilizarov method of external fixation and gradual distraction has been reported as an alternative to conventional techniques. Previous reviews have concluded that this method can provide satisfactory correction and outcome. This study presents a review of 21 resistant clubfeet in 17 patients, who had undergone previous surgery, treated with Ilizarov external fixation and gradual distraction by 1 of 2 surgeons. Outcome measures were graded based on function and presence of residual deformity: (a) excellent (painless, plantigrade foot, with no functional limitations); (b) good (plantigrade foot in a patient able to ambulate long distances with mild pain; (c) fair (mild residual deformity, required bracing, and/or had some functional limitations but an active life); and (d) poor (significant residual deformity, pain, and activity limitations). Radiographic measures of the talocalcaneal and talo-first metatarsal angles were compared preoperatively and postoperatively. At an average follow-up of 6.64 years (range, 2.25-10.50 years), 9.5% (2) achieved an excellent result; 4.8% (1), good; 33.3% (7), fair; and 52.4% (11), poor. All 11 of the feet graded poor required revision surgery at an average of 5.63 years postoperatively (range, 2.67-10.2 years). Only the talo-first metatarsal angle displayed a clinically and statistically significant correction. We conclude that the Ilizarov method for treatment of resistant clubfoot deformities results in poor outcome associated with residual or recurrent deformity, often requiring revision surgery.

Variability in the assessment of acetabular index

This study was undertaken to assess the inter- and intraobserver variability associated with the assessment of acetabular index. Five readers (three senior orthopaedic residents and two pediatric orthopaedic attendings) read each of 24 films on three separate occasions (360 total readings). An independent observer who was blinded to the results of the study assessed whether the radiographs would result in a reproducible acetabular index. Variability was increased for the radiographs that were deemed poorly reproducible by the independent observer. Interobserver variability exceeded intraobserver variability. Variability was comparable for senior orthopaedic residents and attending pediatric orthopaedic surgeons. Even in the group with the least variability (intraobserver variability for reproducible radiographs), the 95% tolerance interval was 8.35 degrees. The results of this study cast doubt on the reliability of the acetabular index based on a single reading.

Surgical risk for elective excision of benign exostoses.

The surgical risk and complication rates for the elective excision of benign osteochondromas and associated surgical procedures is presented. Eighty patients had excision of 285 osteochondromas and underwent 22 other related surgical procedures. There were 10 complications in the group (12.5% per patient population); the most common were peroneal neurapraxias. Other complications included an arterial laceration, a compartment syndrome, and a fibula fracture. The surgical risk for the management of osteochondromas is low and is comparable to the risk of other related, elective procedures. However, osteochondromas should not be routinely excised unless proper indications exist for their removal.

Multidisciplinary treatment for macrometastatic osteogenic sarcoma.

Using a co-ordinated multidisciplinary approach with surgery, radiation therapy, and chemotherapy, 14 out of 21 patients with metastases from osteogenic sarcoma were rendered free of disease for over two to over 18 months. Most patients had pulmonary metastases, two had bony metastases, and one had metastases in the iliac nodes. As part of this multidisciplinary approach weekly high-dose methotrexate was given and caused tumour regression in seven out of 15 patients. After all clinical evidence of disease had been removed high-dose methotrexate was administered every two to three weeks as maintenance treatment. To assess the efficacy of treatment the results were compared with those in a historical control group of 82 consecutive patients who developed pulmonary or other metastases. The results in the study group were significantly better. This experience may be similar to that in Wilmss tumour, where actinomycin D has increased the cure rate when administered as adjuvant therapy after treatment of localised or overt metastatic disease.