Reginald R. Cooper

Morphology of the Osteon: An Electron Microscopic Study

An electron microscopic study of osteons in the cortical bone of the mid-femoral shaft of six adult and four immature mongrel dogs is reported. Embedding was done with a methacrylate for the preliminary study of Haversian canals and with a plastic resin (Epon 812) for the study of intracellular detail. The anatomical features and relationships of the vascular and neural components, the cells (undifferentiated mesenchymal cells, osteoblasts, and osteocytes), and matrix (unmineralized and mineralized) are described. The physiological significance of the morphological findings is discussed on the basis of available evidence.

Influence of Physical Activity on Ligament Insertions in the Knees of Dogs

1. At ligament-bone junctions in dogs existing at varying levels of physical activity, strength diminished as activity diminished. 2. At the proximal end of the tibia, subperiosteal resorption weakened the ligament-bone junction of the medical collateral ligament. A similar change was seen in the fibular attachment of the lateral collateral ligament but not in the other ligament attachments about the knee. 3. Microscopically, widespread subperiosteal bone resorption developed in inactive dogs. 4. Simple caging for six weeks or more produed boen resorption. 5. With continued caging, bone resorption at the ligament-bone attachment healed over a period of six months or more as fibrous tissue replaced resorbed bone and then became mineralized. The widespread subperiosteal bone loss consequent to inactivity probably healed in the same way, suggesting on the basis of this histological evidence that inactivity produces bone resorption which is followed by bone accretion.

Triple arthrodesis: twenty-five and forty-four-year average follow-up of the same patients.

BACKGROUND Triple arthrodesis is used to treat major deformities of the hindfoot and is often performed in young patients. The purpose of this study was to assess the long-term outcomes of triple arthrodesis in young patients. METHODS Sixty-seven feet of fifty-seven patients were evaluated at an average of twenty-five and forty-four years after triple arthrodesis. The most common indication for the operation was neuromuscular imbalance of the hindfoot, which was secondary to poliomyelitis in thirty-seven feet (55 percent), Charcot-Marie-Tooth disease in six (9 percent), spinal cord abnormalities in four (6 percent), cerebral palsy in three (4 percent), and Guillain-Barré syndrome in one (1 percent). RESULTS Fifty-two feet (78 percent) had some residual deformity after the arthrodesis. However, these deformities appeared to be nonprogressive between 1973 and 1994. Pseudarthrosis occurred in thirteen feet. Thirty feet or ankles (45 percent) were painful at the first follow-up evaluation, and thirty-seven feet or ankles (55 percent) were painful at the second follow-up evaluation. Of the thirty feet or ankles that were painful at the first follow-up evaluation, twenty-three were painful at the second follow-up evaluation. Of the thirty-seven feet or ankles that were not painful at the first follow-up evaluation, fourteen were painful at the second follow-up evaluation. Eighteen patients (32 percent) needed walking support at the time of the first follow-up, and thirty-nine patients (68 percent) needed it at the time of the second follow-up. Two of the patients who needed support at the first follow-up evaluation did not need it at the second follow-up evaluation. At the first follow-up evaluation, twenty-one ankles (31 percent) had no radiographic evidence of degenerative changes. However, by the second follow-up evaluation, all of the ankles had some degenerative changes. Similar progressive arthritic findings were noted at the naviculocuneiform and tarsometatarsal joints. According to the system of Angus and Cowell, the overall result at the time of the first follow-up was rated as good in fifty feet (75 percent) and as fair in seventeen feet (25 percent). At the time of the second follow-up, nineteen feet (28 percent) were rated as good, forty-six (69 percent) were rated as fair, and two (3 percent) were rated as poor. CONCLUSIONS Despite progressive symptoms and radiographic degeneration in the joints of the ankle and midfoot, fifty-four patients (95 percent) were satisfied with the result of the operation. The triple arthrodesis was a satisfactory solution for imbalance of the hindfoot in this group of patients.

How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet

Diabetes mellitus and its related complications are increasing at epidemic rates in the United States. Similarly, Charcot foot and ankle deformities are becoming more prevalent. We did a retrospective review of 115 patients (127 limbs) with diabetes mellitus-associated neuroarthropathy to determine the major clinical outcomes. We hypothesized that an intensive disease-specific protocol would result in low rates of amputations. A single treatment protocol was followed for all subjects treated in a tertiary-based orthopaedic department from 1983-2003. Major outcome variables assessed included rates of below-knee amputation, long-term brace wear, reulceration, reconstructive surgeries, and bilaterality. Survivorship analyses were done during a median followup of 3.8 years. In this cohort, diabetic Charcot arthropathy treated in a structured, intensive, and nonoperative manner was associated with an approximately 2.7% annual rate of amputation, a 23% risk of requiring bracing for more than 18 months, and a 49% risk of recurrent ulceration. Limbs with open ulcers at initial presentation or chronically recurrent ulcers had increased risk for amputation. These results suggest that improved methods of care are needed for patients with diabetes who have Charcot arthropathy. Level of Evidence: Therapeutic study, Level IV (case series-no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Long-Term Results of Reconstruction for Treatment of a Flexible Cavovarus Foot in Charcot-Marie-Tooth Disease

BACKGROUND Cavovarus foot deformity is common in patients with Charcot-Marie-Tooth disease. Multiple surgical reconstructive procedures have been described, but few authors have reported long-term results. The purpose of this study was to evaluate the long-term results of an algorithmic approach to reconstruction for the treatment of a cavovarus foot in these patients. METHODS We evaluated twenty-five consecutive patients with Charcot-Marie-Tooth disease and cavovarus foot deformity (forty-one feet) who had undergone, between 1970 and 1994, a reconstruction consisting of dorsiflexion osteotomy of the first metatarsal, transfer of the peroneus longus to the peroneus brevis, plantar fascia release, transfer of the extensor hallucis longus to the neck of the first metatarsal, and in selected cases transfer of the tibialis anterior tendon to the lateral cuneiform. Each patient completed standardized outcome questionnaires (the Short Form-36 [SF-36] and Foot Function Index [FFI]). Radiographs were evaluated to assess alignment and degenerative arthritis, and gait analysis was performed. The mean age at the time of follow-up was 41.5 years, and the mean duration of follow-up was 26.1 years. RESULTS Correction of the cavus deformity was well maintained, although most patients had some recurrence of hindfoot varus as seen on radiographic examination. The patients had a lower mean SF-36 physical component score than age-matched norms, and the women had a lower mean SF-36 physical component score than the men, although this difference was not significant. Smokers had lower mean SF-36 scores and significantly higher mean FFI pain, disability, and activity limitation subscores (p < 0.0001). Seven patients (eight feet) underwent a total of eleven subsequent foot or ankle operations, but no patient required a triple arthrodesis. Moderate-to-severe osteoarthritis was observed in eleven feet. With the numbers studied, the age at surgery, age at the time of follow-up, and body mass index were not noted to have a significant correlation with the SF-36 or FFI scores. CONCLUSIONS Use of the described soft-tissue procedures and first metatarsal osteotomy to correct cavovarus foot deformity results in lower rates of degenerative changes and reoperations as compared with those reported at the time of long-term follow-up of patients treated with triple arthrodesis.

Elastic fibers in human intervertebral discs

Although previous studies failed to demonstrate elastic fibers in intervertebral discs, electron microscopy of twenty human intervertebral discs obtained at autopsy and operation revealed characteristic elastic fibers in both the annulus fibrosus and the nucleus pulposus. Their contribution to the mechanical properties of the intervertebral disc remains to be determined.

Pseudoachondroplastic Dwarfism: A Rough-surfaced Endoplasmic Reticulum Storage Disorder

An estimated 70,000 to 100,000 anterior cruciate ligament reconstructions are performed each year in the United States. With the increasing number of anterior cruciate ligament surgeries being performed, a concomitant increase in intraoperative complications can be expected. Complications include those associated with tunnel placement, notchplasty, graft fixation and advancement, suture laceration, graft laceration, guidewire insertion and removal, intra-articular hardware, posterior cruciate ligament laceration, compartment syndrome, and vascular injury.

The ultrastructure of the growth plate in slipped capital femoral epiphysis.

Core biopsy specimens of the proximal femoral growth plate from three patients with slipped capital femoral epiphysis were studied by light and electron microscopy. In the resting zone, the cartilage matrix was composed of large, densely packed collagen fibrils. The cartilage matrix in the zones of chondrocyte hypertrophy where the slippage occurred contained only scattered fine collagen fibrils in a homogeneous ground substance. The change in composition of cartilage matrix in the distal region of the epiphyseal plate may predispose that region to slippage.

Talectomy. A long-term follow-up evaluation.

Of 26 talectomies with an average follow-up period of 20 years, 24 (92%) were judged to have satisfactory results. The average age at surgery was 10.25 years; however, there is no ideal age for performing talectomies. The results seem to be equally good regardless of the preoperative deformity. The procedure did produce stable, painless plantigrade feet. Talectomy has a place in orthopedic surgery today. However, this drastic procedure is indicated only in those feet where the deformity is rigid and severe, where a plantigrade foot is required in patients who are younger than the age usually recommended for triple arthrodesis, and where experience has shown that other, less radical approaches would be unsatisfactory.

Symposium - Orthopaedic Surgery Fellowships: A Ten-Year Assessment

This symposium is jointly sponsored by the Academic Orthopaedic Society, the American Orthopaedic Association, and the Council on Musculoskeletal Specialties. It gives me great personal pleasure to be able to sponsor a very important topic a little more than one decade after the formal accreditation of the first orthopaedic surgery fellowships. We have a very distinguished panel of participants for the symposium who will address different issues that have arisen or will arise. My task as the moderator is to describe the evolution and the present status of orthopaedic surgery fellowships. I will discuss the definition, history, present number, distribution, and goals of orthopaedic surgery fellowships. Reginald Cooper and James Urbaniak will discuss the impact of fellowships on orthopaedic surgery residencies, patient care, and orthopaedic practice. John Bergfeld will discuss issues relating to the accreditation and certification of fellowships. James Herndon will talk about the ideal fellowship and the problems and challenges of incorporating fellowships into residencies. James Strickland is going to discuss the private-practice model of sponsoring and funding fellowships. Steven Nestler from the Residency Review Committee will show how other specialties accredit and certify their fellowships. Thus, we have a cadre of leaders who are very experienced in orthopaedic surgery assessing the impact of orthopaedic fellowships on all aspects of the practice of orthopaedic surgery and discussing the future of the fellowships in our specialty. Merriam-Websters Collegiate Dictionary defines a fellow as “a person appointed to a position granting a stipend and allowing for advanced study or research.”13 The key words here are person and advanced study or research. Interestingly enough, the Accreditation Council for Graduate Medical Education and the Residency Review Committee do not really recognize the word fellow. If one looks closely at the accreditation materials, be they for residencies or fellowships, one finds that …