Terry R. Light

Anterior approach to hip arthroplasty.

Direct anterior approach to the hip joint utilizing a curved transverse skin incision and splitting the tensor fascia muscle longitudinally provides an effective exposure for carrying out primary total hip arthroplasty. Excellent visualization of the acetabulum is afforded by this direct approach. Modified femoral rasps of varying lengths are employed to rasp the femur with the leg in external rotation. Trochanteric osteotomy was carried out on only three occasions in a series of 104 procedures performed on 85 patients during a three-year period. The duration of operation averaged 65 minutes. Average blood replacement was 1.9 units in unilateral hips and 3.5 units in patients operated upon sequentially. Mean postoperative stay was 12.8 days following unilateral and 22.3 days following bilateral surgery. Four patients experienced perioperative complications. The anterior approach provides a safe and effective approach to total hip arthroplasty with limited morbidity.

Metastatic tumors of the foot: case report and literature review.

Metastatic lesions to the bones of the foot occurred in three elderly patients. Biopsy established the diagnosis in a 90-year-old woman. In a 72-year-old man and a 79-year-old man, the diagnosis was possible from roentgenographic features. In the latter, biopsy of an additional osseous metastatic site established the diagnosis. A thorough review of the literature has yielded 72 previously reported cases of metastasis to the foot. Only 38 of these cases were histologically confirmed. Primary tumors of the colon, kidney, and lung are the most common sources of metastasis to the bones of the foot. Metastatic disease should be considered in elderly patients presenting with foot pain and osteolytic lesions, especially when there is a history of a previously diagnosed malignancy. The generally poor prognosis indicates that treatment should be clearly designed to relieve pain.

The longitudinal epiphyseal bracket: implications for surgical correction.

Summary: Surgical approaches to the correction of deformities in the skeletally immature hand or foot require adequate comprehension of the specific and changing chondro-osseous anatomy of each lesion. Detailed macroscopic and microscopic examination of an abnormal metatarsal showed a trapezoid-shaped diaphyseal/metaphyseal osseous unit that was longitudinally bracketed by a functioning physis and epiphysis along the lateral side. Only the medial side of the diaphysis had a normal periosteum. The arcuate physis extended from the medial, proximal side toward and along the lateral side and then back to the medial side distally. The epiphyseal ossification center was a composite of initially separate proximal and distal secondary centers that had extended toward each other within the laterally placed epiphyseal cartilage. We have termed this deformity a “longitudinal epiphyseal bracket.” We suggest that in the skeletally immature patient, opening wedge chondro-osteotomy should not routinely be accompanied by interposed bone graft extending to either the split ossification center or the physeal cartilage. Such a procedure may induce a partial surgical epiphyseodesis with subsequent progressive recurrence of the angular deformity or cessation of longitudinal growth. Instead, based on our anatomical findings, and preliminary surgical cases, we recommend osteotomy accompanied by fat interposition comparable to the Langenskiöld procedure for traumatic epiphyseodesis.

Correlative roentgenography and morphology of the longitudinal epiphyseal bracket

Detailed examination of a complete chondro-osseous specimen from a patient with duplication of the first ray of the foot revealed the involved metatarsal had a trapezoid-shaped, diaphyseal-metaphyseal osseous unit that was longitudinally bracketed along the lateral side by a functioning physis, epiphysis, and secondary (epiphyseal) ossification center. The physis extended as an arc from the medial proximal side toward and along the lateral side and then back to the medial side distally. The medial side of the diaphysis had a normal periosteum. The longitudinal epiphyseal ossification bracket was a composite of initially separate proximal and distal secondary ossification centers that had progressively extended toward each other and finally coalesced along the laterally placed epiphyseal cartilage. We have termed this deformity the “longitudinal epiphyseal bracket” (LEB). The macroscopic and microscopic anatomy relevant to initial diagnosis and evaluation of sequential roentgenographic changes will be considered.

Complex dislocation of the index metacarpophalangeal joint in children

Four cases of complex dislocation of the index metacarpophalangeal joint prior to skeletal maturity were reviewed. Despite the generalized laxity present in these children, none of the dislocations could be anatomically reduced by closed methods. Two patients had a concomitant osteochondral fracture from the ulnar side of the metacarpal epiphysis; one subsequently developed a lesion similar to an epiphyseal osteochondroma. One patient developed ischemic necrosis leading to premature growth arrest, a shortened metacarpal, and a deformed metacarpal head. The possibility of vascular damage must be considered in the skeletally immature patient, since the epiphyseal and physeal circulation may be compromised by either the dislocation or exposure for the reduction.

PATHOBIOLOGY OF SEPTIC ARTHRITIS AND CONTIGUOUS OSTEOMYELITIS IN A LEATHERBACK TURTLE (Dermochelys coriacea)1

Analysis of a case of presumed hematogenous septic arthritis and osteomyelitis involving the elbow, distal humerus, and proximal radius and ulna in a leatherback turtle (Dermochelys coriacea) showed the chondro-osseous response to be similar to the diseases in skeletally immature humans and terrestrial mammals (both spontaneous and experimental). This particular reptile has bone that is similar to mammalian bone. The infection had partially destroyed the distal humeral, proximal ulnar and proximal radial joint surfaces and epiphyseal cartilages. The elbow was filled with a fibrovascular pannus that had caused a partial ankylosis of the joint.

Salvage of Intraarticular Malunions of the Hand and Wrist: The Role of Realignment Osteotomy

Malunited intraarticular fractures of the hand and wrist may be repaired months following injury by osteotomy through the healed fracture site. If a congruent joint can be reestablished, pain may be relieved while skeletal alignment and motion are improved. Successful reconstruction depends on careful preoperative evaluation and patient selection. Extensile surgical exposure, accurate reduction, and firm skeletal fixation are essential for this technique. Early supervised joint mobilization allows maximal motion. Eight of nine operated joints have regained substantial motion. One procedure failed to establish firm fixation in osteoporotic bone and required arthrodesis. Secondary tenolysis was required on one occasion. An additional patient gained substantial pain relief and motion from limited articular surface resection.

Relationship of 99mTc-MDP uptake to regional osseous circulation in skeletally immature and mature dogs.

Uptake of intravenously injected 99mTc-MDP in multiple regions of healthy skeletally immature and mature dogs was correlated with regional chondro-osseous blood flow determined by radioactively labeled microspheres. Compared to the microsphere distribution, the distribution of 99mTc-MDP indicated that blood flow is an important, but not exclusive, factor in the uptake of bone-seeking tracers. Other factors such as the affinity of the tracer for the various types of chondro-osseous tissues must also affect tracer uptake. A measure of the relative affinity of 99mTc-MDP for bone was derived by the ratio of the percentage of tracer uptake to the percentage of blood flow. The juxta-ephyseal region demonstrated the greatest affinity for the tracer, followed in decreasing affinity, by the cortical bone, epiphyseal cartilage, trabecular bone of the metaphysis and secondary ossification center, and marrow space. Within the spongiosa, affinity generally increased as the proportion of osseous trabeculae relative to marrow space increased. 99mTc-MDP uptake is disproportionately increased in areas of active bone growth and remodeling where the surface area of hydroxyapatite crystals available for adsorption is probably highest.

FRACTURES OF THE RADIUS AND ULNA IN A SKELETALLY IMMATURE FIN WHALE 1

A naturally-occurring fracture of the distal radius and ulna in a skeletally immature fin-whale, Balaenoptera physalus, appeared to be failing to heal. When compared to the response to fracture in the skeletally immature human and to other terrestrial mammals, this animal did not show any endosteal and only minimal subperiosteal callus, even though the fractures appeared to be several weeks, if not months old. This suggests that the larger ceteceans may not be able to respond appropriately to skeletal injury in the major structural units of the flipper.

Pediatric osteomyelitis: III. anaerobic microorganisms.

Primary osteomyelitis consequent to obligate anaerobic microorganisms represents an infrequently encountered type of infection in pediatric patients. Unlike osteomyelitis caused by more common microorganisms such as Staphylococcus, children with osseous lesions due to anaerobic microorganisms are frequently minimally symptomatic and rarely present the classic signs of fulminant osteomyelitis. Radiographically, the lesions may mimic malignant osseous tumors. Fastidious microbiologic analysis of the material obtained at surgery is necessary to isolate obligate anaerobes. Basic treatment, comprising surgical drainage and appropriate antimicrobial agents, does not differ from that for osteomyelitis caused by aerobic or by facultative anaerobic microorganisms.