Tillman M. Moore

Tibial plateau fractures: definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction.

Results of a decade of experience with 988 tibial plateau fractures are presented. Maximum plateau depression was measured on initial and follow-up x-ray studies, and knee instability was clinically evaluated to identify minor and major fractures as a guide to management. Demographic, treatment, and complication data were gathered prospectively in 753 fractures. Four hundred thirty-seven “major” tibial plateau fractures (44% of cases) were treated operatively; the remainder were treated by traction. Three hundred twenty patients who sustained only a plateau fracture were followed from 1 to 10 years, with an average of 3.7 years. Nonsurgical treatment included Bucks traction (89% of closed treatment cases) or a “knee exerciser” device utilizing skeletal traction in a Hodgson-Pearson apparatus. Early intermittent passive and active knee motion was encouraged. The complication rate of traction was 8%. The complication rate in operated patients was 19%, much of which was due to infection. Methods for objective and subjective scoring of both traction and operative results were developed and utilized. Results show that anatomic reduction of plateau fractures, in addition to early motion, is a major factor contributing to successful management of this potentially disabling injury.

Traumatic dislocation of the knee joint

The results in thirty-three of fifty-three traumatic dislocations of the knee followed for more than one year confirmed our conclusion, made in 1971, that early repair of all torn ligaments gives the best results, and that the vascular status following this injury must be observed carefully since vascular repair or thrombectomy within eight hours of injury gives the best chance of preventing gangrene of the leg. The twenty associated fractures in these thirty-three patients were treated successfully with conventional methods, except for three displaced fractures of the medial tibial plateau in which closed reduction failed and internal fixation was required.

Allograft Transplantation in the Knee: Tissue Regulation, Procurement, Processing, and Sterilization:

Use of musculoskeletal allografts has become increasingly popular, with widespread use among knee surgeons. The advantages and disadvantages of their use have been documented. In the knee, allografts are used for ligament reconstruction, meniscal transplantation, and articular surface reconstruction. The purpose of this review is to present issues surrounding the allograft industry, including regulation of tissues and tissue banks and procurement, processing, sterilization, and storage of allograft tissue. Tissue bank regulation is ultimately under the jurisdiction and authority of the Food and Drug Administration; some individual states regulate tissue banks. The American Association of Tissue Banks is a scientific organization that encourages education, research, and voluntary accreditation of tissue banks. It promotes safety and standards for retrieval, processing, storage, and distribution of transplantable human tissue. Allograft tissues are generally harvested and processed aseptically, which may not prevent contamination. Tissue sterilization is difficult and controversial. Tissue banks historically have used one of two methods of sterilization, ethylene oxide or gamma radiation. Both methods have risks and benefits. Newer methods of sterilization are being developed. Allograft tissue that is not transplanted fresh can be freeze-dried or deep frozen for storage. Ultimately, allograft transplantation in the knee facilitates knee form and function and enhances the patients quality of life. Orthopaedic surgeons who use allograft tissue must understand the tissue banking process to provide safe and effective tissues to their patients.

Effects of gamma irradiation on the human immunodeficiency virus. A study in frozen human bone-patellar ligament-bone grafts obtained from infected cadavera.

We studied the effects of several different doses of gamma radiation, ranging from 20,000 to 40,000 gray (2.0 to 4.0 megarad), with respect to the inactivation of the human immunodeficiency virus in fresh-frozen, whole bone-patellar ligament-bone grafts. Although the International Atomic Energy Agency has recommended the use of 25,000 gray of gamma radiation for the sterilization of medical products, the dose required for the inactivation of the human immunodeficiency virus in frozen allografts has not been established. Using one of the most sensitive and specific tests for the detection of the human immunodeficiency virus, the polymerase-chain-reaction test, we found that doses of 20,000 or 25,000 gray of gamma radiation did not destroy the genes of the human immunodeficiency virus effectively; DNA of the virus was detectable in the DNA of bone-marrow tissue obtained from grafts treated with these doses. However, DNA of the human immunodeficiency virus was not detectable in the grafts treated with 30,000 or 40,000 gray of gamma radiation. We conclude that a dose of 30,000 gray of gamma radiation or more is necessary for the sterilization of a fresh-frozen bone-patellar ligament-bone allograft, so that it can be used for reconstructive procedures without the risk of transmission of the virus to the recipient.

Analysis of 61 cases of vertebral osteomyelitis

Sixty-one cases of bacterial vertebral osteomyelitis from July 1969 to July 1979 were analyzed. The ages of the 49 men and 12 women ranged from 21 to 66 years. The portal of entry was hematogenous in 58 cases, gunshot wounds in two cases, and and adjacent retroperitoneal abscess in one case. Biopsy was performed in 60 patients. There were 15 complications related to the disease. Gram-negative rods were the predominant bacteria isolated. Blood culture was positive in 13 of the 26 (50%) patients tested. Eleven of the 13 (85%) organisms isolated from the blood cultures correlated with organisms recovered from biopsy specimens. Eleven of the patients had more than one disk level involved. Of the 61 patients, 29 went on to spontaneous fusion, 17 were lost to follow-up study, 11 failed to fuse, three had surgical fusion, and one patient died. Recommendations for diagnosis included the collection of blood cultures and radionuclide bone scans. Management recommendations included systemic antibiotics for at least three weeks and immobilization with either bed rest or spinal orthoses. Surgery was indicated if an abscess was present, neurologic complications occurred, instability became a factor, or the medical treatment failed.

Closed biopsy of musculoskeletal lesions.

Five hundred and thirty-one closed biopsies have been done in our general hospital since 1967. Four hundred and eighty-four were for lesions of bone and forty-seven were for soft-tissue lesions. More than half of the lesions were infections or nonspecifically reactive. The procedure was done under local anesthesia in 73 per cent and roentgenographic or image-intensifier control was generally required. The Craig needle was used for cancellous bone near vital structures; the Michele trephine, for cortical or sclerotic bone at a distance from vital structures; and a special needle was used for soft tissue. Closed biopsy provided an adequate specimen that was accurately diagnosed in 66 per cent of bone lesions and in 76 per cent of soft-tissue lesions. This compared favorably with both aspiration and open-biopsy success rates reported by others, and was accompanied by a 1 per cent complication rate, mostly neural and mostly in association with vertebral lesions.

Results of compression-plating of closed Galeazzi fractures.

Diaphyseal fractures of the distal third of the radius that are associated with disruption of the distal radio-ulnar joint accounted for eighty-four (6.8 per cent) of 1236 fractures in the forearm that were treated during a five-year period at the Los Angeles County-University of Southern California Medical Center. Thirty-six closed Galeazzi fractures, twenty-eight in male and eight in female patients, were followed for 1.5 to seven years after treatment using standard AO-compression plates with four to seven holes. Complications included seven injuries to the sensory or dorsal interosseous branch of the radial nerve, two infections, two non-unions, two re-fractures after plate removal, and shortening of the radius of five millimeters in one patient. The complication rate was 39 per cent. The average grip strength at follow-up was 71 per cent of the calculated normal value. The loss of strength was not related to use of a volar or dorsal surgical approach, the patients age, or a delay of surgery for more than ten days after injury. The average loss of grip strength in the seven upper extremities with restricted motion of the wrist and forearm was 48 per cent, compared with an average loss of 29 per cent in the whole group. Of the twelve patients who were operated on more than ten days after injury, six had loss of motion at follow-up, compared with three who had such a loss among the twenty-four patients who were operated on within ten days after injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenosquamous carcinoma of the lung and the acquired immunodeficiency syndrome.

Excerpt To the editor: Kaposis sarcoma, squamous cell carcinoma of the buccal mucosa, and lymphoid malignancies with or without opportunistic infections have been described in homosexual men with ...

Treatment of displaced subcapital and transcervical fractures of the femoral neck by muscle-pedicle-bone graft and internal fixation. A preliminary report on one hundred and fifty cases.

Beginning in 1967, all qualified patients (under seventy years of age, ambulatory with a displaced femoral fracture in the neck or subcapital) were treated either by use a fibular graft (twenty-one not considered in detail in this report) or by an iliac graft with quadriceps muscle pedicle in addition to Hagie pins. Four of the 150 patients were lost to follow-up. There were seven deaths and three infections which required removal of the femoral head. Of the remaining 136 patients, there were fifteen non-unions (11 per cent). When, in addition, a posterior defect was found and was filled with bone graft, union occurred in 97 per cent (sixty-four of sixty-six). Of the fifteen non-unions, eight had unsatisfactory reductions or were in uncooperative patients. Late segmental collapse occurred in five patients (of sixty-three followed eighteen or more months) and varus position in sixteen. At follow-up, five patients were practically confined to a wheel chair, fifteen used a walker and seventeen a cane, while the rest were freely ambulatory.

Collateral ligament laxity of the knee. Long-term comparison between plateau fractures and normal

Bilateral varus-valgus knee-stress roentgenograms were made in 208 patients with unilateral single tibial-plateau fracture. Martins so-called clear space was used to measure the laxity of the collateral ligaments and statistical analysis showed no increased laxity in the possibility injured ligaments. A vacuum phenomenon was produced in 36 per cent and ligament calcification was noted in 16 per cent of the knees tested.