John J. Williams

The Lateral pillar classification of Legg-Calve-Perthes disease

To determine the predictive value of a new classification system for Legg-Perthes, 93 hips in 86 patients with radiographic follow-up to maturity were reviewed. All patients were treated by bracing at the Texas Scottish Rite Hospital from 1970 to 1980. Hips were classified during the fragmentation stage of disease into three groups based on radiolucency in the lateral pillar of the femoral head. Final radiographs were reviewed at skeletal maturity, and the outcome was determined according to the Stulberg classification. Group A had a uniformly good outcome (100% Stulberg I and II results); Group B had a good outcome in patients who were <9 years at onset (92% Stulberg I and II, 8% Stulberg III results), but a less favorable outcome in patients who were >9 years at onset (30% Stulberg II, 50% Stulberg III, and 20% Stulberg IV results). In Group C, the majority of femoral heads became aspherical in both age groups (29% Stulberg II, 52% Stulberg III, and 19% Stulberg IV results). The group C hips also had a longer duration of fragmentation and reossification stages. Members of the Legg-Perthes study group agreed 78% of the time when applying the classification to unknown radiographs. The classification group was a stronger determinant than age of onset in predicting final outcome. This classification system is easy to apply during the active stage of the disease and has a high correlation in predicting the amount of flattening of the femoral head at skeletal maturity. When combined with age at onset, it can be used to predict the natural history of the disease and evaluate various forms of treatment.

Late knee problems in myelomeningocele

Summary: This study was undertaken to assess the incidence and etiology of knee problems in a long-term follow- up of myelomeningocele patients. Of the 72 community ambulators reviewed, 17 (24%) had significant knee symptoms. A specific gait pattern was identified in symptomatic patients with low lumbar lesions, which may be explained on the basis of hip abductor and calf muscle weakness. These patients have a characteristic gait, which places abnormal stress on the knee, leading to medial and anteromedial rotary instability and eventual degenerative change. It is likely that disability resulting from knee symptoms will be the factor precluding independent ambulation in the patients reviewed in this study.

Evolution of Femoral Head Deformity During the Healing Phase of Legg-calvé-perthes Disease

Progressive changes in the roundness of the femoral head were noted during the healing phase of hips with Legg-Calvé-Perthes disease. Forty-nine of 136 hips studied became progressively rounder, and 15 hips became progressively flatter after onset of reossification of the femoral head. The femoral head was more likely to undergo progressive flattening in older patients, in those with more severe lateral pillar involvement, and in those with prolonged reossification. These changes occurred during a 3− to 4-year reossification period after cessation of treatment.

Pulmonary endothelial injury and altered fibrinolysis after femur fracture in rabbits

The pathophysiology of acute lung injury after long bone fracture may be associated with endothelial damage and altered fibrinolysis. Accordingly, we studied metabolic functions of pulmonary endothelial cells: 5-hydroxytryptamine (5-HT) uptake and angiotensin-converting enzyme (ACE) activity in anesthetized rabbits before and every 4 h after long bone fracture (n = 12) or sham (n = 6). To assess changes in fibrinolysis, we studied levels of plasminogen activator inhibitor (PAI), an inhibitor of the fibrinolytic cascade. All animals in the control group and only 6 of 12 animals in the long bone fracture group survived 12 h. 5-HT uptake was depressed after 8 h in both groups. By 12 h, however, 5-HT uptake in the long bone fracture group remained depressed, but returned to baseline in the control group. Conversely, ACE activity was unchanged in both groups. PAI levels were increased in both groups at 4 h. During the next 8 h, levels in the long bone fracture group continued to increase and remained elevated, whereas levels in the control group decreased and were not greater than baseline at 12 h. Initial PAI and 5-HT uptake changes may be related to surgical preparation of the rabbit. Prolonged depression of 5-HT uptake suggests that musculoskeletal trauma is associated with pulmonary endothelial damage. Finally, impaired fibrinolysis due to increased PAI may contribute to the pathogenesis of endothelial injury after long bone fracture.

Radial neck fracture complicating closed reduction of a posterior elbow dislocation in a child: case report.

A case of radial neck fracture complicating repeated attempts at closed reduction of a posterior elbow dislocation in a child is described. This case underscores the necessity of using proper technique when reducing posterior elbow dislocations. The mechanism of radial neck fracture in association with posterior elbow dislocation is discussed.