Lowell F. A. Peterson

The Extra-osseous and Intra-osseous Blood Supply of the Talus

The talus is supplied with blood by the three main arteries of the leg through a periosteal vascular network and also by two discrete vessels, the artery of the tarsal sinus arising from the dorsolateral arteries and the artery of the tarsal canal arising from the posterior tibial artery. At dissection an artery of the tarsal sinus was found in five specimens, and an artery of the tarsal canal was found in thirteen specimens. The intra-osseous vascular pattern was visible in all specimens after decalcification, sectioning, and clearing by the Spalteholz technique. The head is supplied by vessels entering from the superior surface of the neck and the inferolateral aspect of the neck which faces the tarsal sinus. The body is mainly supplied by vessels which enter antero-inferiorly through the neck of the talus and by vessels which enter through the medial surface below the articular facet. Smaller vessels enter the body from the superior surface of the neck, the anterolateral surface of the body, and the posterior tubercle.

Arthrodesis of the knee following failed total knee arthroplasty.

In forty-five patients, who had an arthrodesis because of failed total knee arthroplasty, the cause was infection in forty, instability in two, failure of the prosthesis in two, and loosening in one. The arthrodesis succeeded in twenty-nine (81%) of thirty-six patients who had had a minimally or partially constrained arthroplasty and in five (56%) of nine who had had a hinge-type prosthesis inserted. The reasons for failure were severe bone loss, persistent sepsis, and loss of bone apposition after manipulation. The technique of arthrodesis did not seem to influence the final result. External fixation most commonly had to be used because of the infections and the device was kept in place for an average of ten weeks, after which immobilization in a cast was used until the arthrodesis healed.

Bacterial Colonization of Wounds and Sepsis in Total Hip Arthroplasty

This is a study of 658 consecutive total hip arthroplasty procedures in which cultures were taken at surgery. Cultures were positive in 195: 111 occurred in 437 hips that had not been previously operated on and eighty-four in 221 hips that had undergone previous operation. To date, there have been fourteen infections: seven superficial, and seven deep. Preliminary data indicate that the presence of a positive culture in a hip previously operated on may be significant, even though a deep wound infection may later yield a different organism. Organisms belonging to the family Micrococcaceae appear to predominate in deep wound infections.

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.

Carpal-tunnel Syndrome Associated with Vasospasm

Twenty-eight patients with concurrent carpal-tunnel syndrome and Raynauds phenomenon or acrocyanosis were studied. Fifteen had a definite diagnosis or presumptive evidence of a systemic disease. Thirteen patients were treated conservatively and fifteen had decompression of the transverse carpal ligament. All patients treated surgically had an excellent result in regard to the carpal-tunnel symptoms, whereas in the group treated conservatively only three showed improvement. Six patients treated surgically had excellent or good results in regard to their vascular symptoms and nine had fair or poor results; in the group conservatively treated, one noted improvement and ten were unchanged or worse. Early surgical treatment of these combined syndromes appears warranted.

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.

Mastocytosis with Osseous Lesions Resembling Metastatic Malignant Lesions in Bone

Seven cases in which osseous lesions of mastocytosis resemble metastatic malignant lesions in bone have been reported. Mast cells, a normal connective-tissue element with complex physiopharmacological aspects, may proliferate abnormally and produce an unusual clinical syndrome: mastocytosis. The skin is usually the first and often the only organ involved. The resultant rash (urticaria pigmentosa) has a somewhat varied appearance but characteristically urticates or flushes with trauma. In a small percentage of patients, the disease affects other organs, particularly the liver, spleen, and skeleton. The skeletal manifestations are often confused roentgenographically with those of metastatic carcinoma, as is manifested by the sequence of events in four of the seven cases reported here. Extensive osseous mastocytosis most closely resembles the myelosclerosis of agnogenic myeloid metaplasia. Typically, the differential roentgenographic features of osseous mastocytosis are the following: 1. The predominantly epiphyseal location in the long bones if scattered discrete lesions are present; 2. The sclerotic halo enveloping discrete lytic foci; 3. The uniform but non-homogeneous medullary distribution if extensive osteosclerosis is present; 4. The slight to moderate hepatosplenomegaly. In most instances, the suspicion of the presence of osseous mastocytosis can be quickly substantiated by checking the patients skin. Additional confirmation by bone biopsy is desirable although the number of mast cells in a given specimen may not be increased. Final diagnosis depends on correlation of the cutaneous, clinical, roentgenographic, and pathological findings. Treatment is directed primarily at controlling symptoms produced by the elaboration of histamine by the abundant mast cells and at the secondary complications of systemic mastocytosis. Prognosis depends on the organs involved and the extent of the disease.

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 effect of high-dosage ultrasonic energy on femora of the dog: a roentgenographic, histological, and microangiographic study.

The femora of thirteen dogs were exposed to high levels of ultrasonic energy. Alterations became evident on roentgenograms two weeks after such exposure. Death of cortical bone was evident histologically three and four weeks after exposure, the shortest time interval after exposure that bone was studied histologically. The periosteal and the endosteal responses proximal and distal to the area of necrosis consisted of periosteal and endosteal formation of new bone with a marked increase of the periosteal and endosteal vessels. These changes are interpreted as being secondary to the death of the segment of diaphyscal bone exposed to ultrasonic energy. Whether the death so produced is purely thermal or is due also to non-thermal effects is not known to us at this time. That ultrasonic energy can be focally destructive to bone and its blood supply seems apparent.