Joseph M. Janes

Swan-neck deformity following extensive cervical laminectomy. A review of twenty-one cases.

Twenty-one patients, thirteen to sixty-two years old, were treated for cervical swan-neck deformity after extensive laminectomy (with or without foraminotomy), performed for cervical-disc syndrome in nine, spondylosis in six, syringomyelia in three, cord tumor in two, and old fracture-dislocation with nerveroot compression in one. Spontaneous fusion occurred in one patient after prolonged bracing. In the other twenty, the results of surgical stabilization (three posterior and seventeen anterior fusions) were excellent in nine, good in one, fair in four, and poor in six. It was concluded that bracing after extensive laminectomy is indicated, and may prevent this complication; that early recognition and anterior fusion are essential to prevent fixed severe deformity; and that fusion must extend the full length of the laminectomy.

Blood Supply of the Human Tibia

The study of fourteen limbs of adult human beings by various techniques yielded the following description of the tibial blood supply. The epiphyseal-metaphyseal regions are generously supplied by vessels entering from the periphery. These vessels anastomose with vessels from the diaphyseal area. The nutrient artery is the main source of blood to the diaphyses. It gives off ascending branches immediately after it enters the medullary cavity, and these branches disperse widely. The descending branch, on the other hand, remains as a single major vessel for some distance before finally dividing. The ascending and descending branches of the nutrient artery give off radial twigs that enter the cortex. These small arteries supply the vessels of the Haversian systems. The periosteum has a copious vascular bed that contributes only infrequent capillaries to the vascular system of the cortex. Some of these capillaries traverse the cortex from periosteum to endosteum and probably represent anastomotic links with the branches of the nutrient artery. An additional anastomosis consists of the vessels in the secondary Haversian canals, as described by Ham. The venous drainage of the diaphysis is largely toward the endosteal surface through veins that accompany the arteries. At irregular intervals, however, venous channels also drain to the periosteal surface. The venous drainage of the epiphyseal region is by way of vessels adjoining the radially arranged arteries.

DIFFUSE PIGMENTED VILLONODULAR SYNOVITIS OF THE HIP JOINT. REVIEW OF THE LITERATURE AND REPORT OF FOUR CASES.

Analysis of eight cases of diffuse pigmented villonodular synovitis of the hip joint and a review of the literature indicate that the disease was most common in persons in their fourth and fifth decades of life. In our series of seven women and one man, the duration of symptoms ranged from two and one-half to eleven years. Typical symptoms included increasing pain in the involved hip and a limp. In all cases the disease was monarticular and there were no systemic symptoms. Roentgenographic findings were cystic changes in the acetabulum and the femoral head and neck, narrowed joint space, and occasional diffuse sclerosis of the femoral head. Needle biopsy was the most useful diagnostic procedure. Treatment included complete synovectomy in all eight patients, arthroplasty with a Vitallium cup in six, and an Austin Moore prosthesis in two. Three patients had radiotherapy. Meticulous synovectomy and grafting of the cysts combined with cup arthroplasty are recommended for treatment of this disease. Our experience with the Austin Moore prosthesis in this disease is too limited to assess its value. It is our current belief that if the femoral head is destroyed by cystic changes, an Austin Moore prosthesis should probably be used.

Ultrasonic energy and surgically produced defects in bone.

A study was made of the effect of ultrasonic energy on the healing of defects created surgically in the femora of sixty-seven dogs. The ultrasonic energy was applied to anaesthetized dogs with a power ranging from five to twenty-five watts in various groups of animals. Stimulation of the healing of these defects its bone was not seen. Instead, a delay in healing associated with medullary fibrosis and necrosis of bone was noted. This agrees in part at least with work reported by others. In view of recently reported studies claiming stimulation of the healing of fractures following use of a different technique of ultrasonic application and smaller doses, the need for further investigation along these lines is obvious. It is probable that more frequent and less concentrated exposures, with use of a technique and dosage comparable to those used clinically, applied to non-anaesthetized animals would provide the answer to this question. Now that the effects of more intensive amounts of energy have been studied, this would appear to be the next step.

The Effect of Arteriovenous Fistulae on the Vascular Pattern of the Femora of Immature Dogs

Time l)allcitV of knowledge oim i)loo(i Sup )ly of bone is readily ttl)l)arelmt to those iimtereste(! iim timis fuimt!aimmental factor of boime growtim aimd I)ofle immetabolisimm. Timis fact imas i)een elmmplmaSiZed by Trueta. Tilling recently revie ved the literature oim time vascular aimat.oimmv of long I)Ofles, but only twenty-tlmree articles ttl)l)eLtl’e(l ill lmis i)ibliograplmy. Timis simmail nuimiber indirectly 1)OifltS up our limmmited knowle(!ge of timis subject. Time experiimmeimtal work wimicim foi’imms time basis for timis paper is i)art of a large )I’0 t’ct i)eing carl’iet! out at time \Iayo Clinic to iimvestigate time blood supply of bone. Time tecimnique of umicroangiograpimy being used in timis study has been rel)ortet! 10 Otimer immt’timods also being ust’ti at time Mayo Clinic imave beeim (iescribed i)’ T Haliburton ant! co-workers in timeir i’el)Ort on time blood SUp )ly Of time talus. Time fact timat an arteriovenous fistula woult! increase bone leimgtim was ImOte(i iim 1870 by Broca, and in 1950, one of us (.J. M. .1.) and Musgrove reported timat arterioveimous fistulne would promote time growtim of bone in immature (logs. Pearse anti i\Iorton, an(1 WU aimd Miltner also alluded to time effect of i)loo(! supply on bone growtim. Tlmeir publications, an(i a ti’anslatioim of a immoimograplm i ’ Bier, 11’ovide an exteimsive i)ii)liogra )imy on soimme of time early observations on time relatioimships i)etweelm i)loo4Il sup )ly of i)one alm(l i)one growtim. Hutcimison an(1 Burdeaux Imave ilmcrease(l time length of boimes in (logs i)y Usiimg toiii’imiquets to obstruct yeimous i’etui’im. In time last two years, immicroaimgiograpimy Imas ap )eaI’e(l to be a \‘alUai)le tecimnique for our st.u(ly Of time effect of an arterioveimous fistula oim bone, aimti we lma ’e carefully reviewed t he (levelol)imment of timis specialized techlmique of immicroaimgiogra )imy.

Criteria for Determining the Proper Level of Amputation in Occlusive Vascular Disease

Experience with amputation in occlusive vascular disease at the Mayo Clinic for a five-year period indicates that the history of onset, the physical findings, and the ulimate prognosis should all be taken into account before one embarks on a conservative amputation. When there is a good change of rehabilitation of the patient, one may be justified in doing an amputation below the knee in less than ideal eircumstances. The fact that thirteen of twenty-two patients who had serious wound complications were able to use prostheses supports this viewpoint; in only two of these twenty-two patients was the stump incapable of supporting a prosthesis because of instability of the stump. Toe amputation can be expected to be successful only in thromboangiitis obliterans and in selected diabetic lesions. Use of a prosthesis does not unduly jeopardize the other leg.

The Lack of Effect of Microwave Diathermy on Rate of Growth of Bone of the Growing Dog

IuItei’i()veusous fistullu has beets studied at the ) 1av() (1liusic. The results of these investiglutiouss ttusd studies of other issethods have beets discussed iii detail . Since local 1syperthernsi u appeltre(l to be 15 IlIlijOr factor in all of the previous studies, we thought tilttt. puililltry cliu-ect heating of uts 1tt( 1t of nsajor gu-ow’th should 1)e invest ugateci. \1icro’sva ’e dilttheu-nsy \\‘as selected for the experinseusts to be descuibed in this u’epou’t. Tisis tuelutullent pu’odiuces 1)iologiclul effects simssil uu to those produced by otisem’ forlsls of (Iilutheunsy. A tenspem-ature increase of 3 to 5 deguees cetitigrlude its the til)ja of dogs Itfter exposuue to nsierowluve diathernsy of sixty-five watts at tt. (listlulice of’ t’svo itiChes \\‘Ils repou-ted by Etsgle Iuusd lussociates. SiIsiillur results isave i)een uei)orte(1 lot othei experuilseuittul luuuillsluls slid for maii

GROWTH AND STRUCTURE OF BONE DISTAL TO AN ARTERIOVENOUS FISTULA: QUANTITATIVE ANALYSIS OF TETRACYCLINE-INDUCED TRANSVERSE GROWTH PATTERNS

Puppies in the second half of their growing period have been observed for one and a half to four and a half months after creation of a superficial femoral arteriovenous fistula on the right side. From measurements of the whole bone and from microradiographic and tetracycline-fluorophore studies of the diaphysial bone, it is believed that the following statistically significant phenomena may be attributed to the influence of the arteriovenous fistula. 1. All bones distal to the fistula are influenced in their growth. The tibia and metatarsals become heavier and larger, but retain normal shape. Although stimulation of longitudinal growth is small, it is significant for the tibiae and nearly significant for the femora in these short-term experiments. 2. The histological structure of the bones remains normal but quantitative changes are induced. The compact bone is more porous because of an increased number of osteones. Haversian turnover itself is affected in that the individual formation time of osteones tends to become longer, especially in the metatarsals. 3. Periosteal new bone formation is immediately stimulated, producing a flare of new bone. This accounts for the increase in diaphysial weight in the tibia but not in the metatarsals, where the same effect results from decreased resorption of old bone. 4. Endosteal new bone formation is depressed, especially in the metatarsals, resulting in an enlarged medullary cavity.

The effect of beryllium on bone. A morphological study of the progressive changes observed in rabbit bone.

A series of fourteen rabbits were studied by roentgenograms made twice a month after injection of zinc beryllium silicate. After death or sacrifice, twelve long bones from ten rabbits were studied by microradiography and celloidin-embedded contiguous sections stained by hematoxylin and eosin. Spalteholz preparations of bones from four additional rabbits were also studied after injection of the arterial tree with a mixture of gelatin and India ink. The following observations were made: Medullary formation of bone was detected from the roentgenograms made eight to sixteen weeks after the last injection in all fourteen rabbits. Microradiography disclosed that this bone had a higher mineral content than the surrounding normal bone. In certain areas in this medullary bone, the lacunar spaces were blurred or indistinct on microradiography. Contiguous histological sections revealed that similar areas in sections stained by hematoxylin and eosin were devoid of cells. Therefore, it is postulated that the blurred lacunae evident in the microradiograms represent areas where the cells have died and mineralization of the empty lacunar spaces has occurred. Part of this phenomenon may be due to the direct cytotoxic effect of the zinc beryllium silicate seen in marrow spaces adjacent to the apparently non-viable, acellular bone on the surface of viable trabecular bone. Also, this phenomenon may be due to a decrease in vascularity caused by blockage of the blood supply by the abnormal bone. The decrease in vascularity, however, could be due purely to the cytotoxic effect of beryllium. Osteogenic sarcoma made its appearance thirty to fifty-two weeks after the last injection of beryllium. The morphological appearance of this phase is commented on, particularly the differences between the timorous bone and the abnormal medullary bone of beryllium poisoning and the similarity between this tumor and human osteogenic sarcoma.

The influence of splenectomy on the induction of osteogenic sarcoma in rabbits.

Osteogeiiic sar(-omna mnay be imiduced iii rabbits by the intravenous imijectiomi of zimic beryllium silicate5’ 6, 8#{149} Imi 1952 the authors undertook the experimemit.al productiomi of such tumors in order that they might have miiat.erial on which they could test the therapeutic effectivemiess of ultrasomiic energy 12 In this initial study it was found that when zimic beryllium silicate was givemi to miormal rabbits, osteogemiic sarcomata were produced in 50 per cent of the animals. These tumors arose in the medullary cavities of the long bones and extended through the cortices into the surroumiding soft tissues. Metastases w’ere found frequemitly in the lungs and less oftemi imi the liver. In these experiments the spleen appeared to play sonic role in tumorigenesis, for in all the amiimals in w-hich tumors developed, there w-ere atrophic changes within the spleen, whereas ill those animals in which tumors did not develop after the administratiomi of beryllium the spleens were functional amid hyperplastic. Others have also noted changes in the spleens of rabbits in which bone tumors have been produced 6. The imiitial respomise in the spleemis of these experimental rabl)its following the inject.iomi of beryllium was an extemisive phagocytosis of the beryllium by the histiocytes of the spleemi in a maminer similar to that described by Baillif in his study of colloidal thorium. Rapid degemierative changes then occurred in these histiocytes, leading to their destruction. This was follow-ed by au apparent transformat.iomi of the reticuloemidothelial COlUponents of the malpighian corpuscles into miew functional histiocytes, w’hich, in their turmi, were destroyed by the beryllium which they attempted to isolate . In this manner functional splemsic tissue was slow’ly destroyed and this usually vascular cellular organ degemicrated imito ami avascular fibrous remmiamit, hardly discermsible in the splenic ligamemit. Bomie tumors invariably developed in the rabbits in w-hich splenic atrophy had occurred, whereas in the rabbits that remained tumor-free for months after the imijections of beryllium the spleens were essentially normal. During recent years a considerable volume of data has beemi assembled indicating that the spleen plays a role in protectimig the organism against. the lethal effects of ionizing radiatiomis. It is kmiown that total-body irradiatiomi is a most important exogenous leukaemic agemit in mice 13, and in recent experiments w’ith mice it. has been shown that when the spleen is removed the imicidence of tumors following comparable exposures is imicreased 14 amid that when the spleen is shielded during irradiation of the body, recovery is more rapid amid survival time is prolonged 1O In experiments by Jacobson the mere implamitation of the spleen into the peritoneal space of irradiated animals demonstrated the prote(-tive mole of the spleen 9. 1 . Imi other experiments in which C57 black mice were used, shielding of the spleemi effectively decreased or prevemited the induction of lymphoid tumors l6