The career and orthopaedic injuries of Joshua L. Chamberlain. The hero of Little Roundtop.

Joshua L. Chamberlain, a professor of religion and oratory at Bowdoin College, Brunswick, Maine was commissioned Lieutenant Colonel of the 20th Maine Volunteer Regiment in August 1862. He commanded the 20th Maine Volunteer Regiment in the historic defense of Little Roundtop against overwhelming odds and circumstances during the pivotal battle of Gettysburg. In June 1864 while leading a charge at the battle of Petersburg, he sustained what was thought to be a mortal wound when he was struck by a minié ball that entered just below and anterior to his right greater trochanter, injuring vessels, the urinary bladder and urethra, and fracturing his pelvis. Surgery was done in the field hospital, and after 5 months of recuperation, Chamberlain returned to lead his troops in combat. After the war he was elected Governor of Maine for four terms and subsequently served as President of his alma mater, Bowdoin College, for 12 years. Despite the fact that he had chronic lower abdominal pain, wound drainage, and a persistent urethral fistula, he lived a very productive life for 50 years after he was wounded at Petersburg. Included in the current paper are commentaries on the state of the art of surgery during the Civil War.

Femoral pulse as a guide to the mechanical axis in total knee arthroplasty.

The anatomic relationship of the center of the femoral head to the femoral artery was studied in 140 hips in 70 patients. The coronal plane distance between the femoral artery 2.5 cm below the inguinal ligament and the center of the femoral head was measured on pelvic arteriograms. The femoral artery was found an average of 7.7 +/- 5 mm medial (range, -3-22 mm) to the center of the femoral head. The femoral artery was within 15 mm of the center of the femoral head in 93% of cases reviewed. A 76-cm theoretical mechanical axis was used in estimating clinical angular changes in the axis for a given coronal plane difference. By use of this model, the range of variability translates into a maximum change in the mechanical axis of 1.66 degrees and up to only 1.2 degrees in 95% of the cases reviewed. A marker placed just lateral to the palpable femoral pulse approximately 2 to 3 cm below the inguinal ligament is suitable as a guide to locate the center of the femoral head when determining the mechanical axis during total knee arthroplasty.

Efficacy of corticosomatosensory evoked potential monitoring in predicting and/or preventing sciatic nerve palsy during total hip arthroplasty.

Sciatic nerve palsy (SNP) is one of the most distressing complications associated with total hip arthroplasty. The authors used corticosomatosensory evoked potential monitoring in 290 consecutive patients in an attempt to predict when SNP might occur and to prevent its occurrence by changing the position of the retractors and/or the operated limb in response to intraoperative waveform changes. Despite these efforts there were 8 SNPs among the 290 patients (2.8%). The authors compared this group with 485 consecutive patients who were not monitored. In the latter group there were 13 SNPs (2.7%). There were two monitored patients (0.7%) with no intraoperative evidence of SNP who exhibited SNP after surgery (false negatives). Corticosomatosensory evoked potential monitoring was found to be neither effective in predicting SNP nor helpful in its prevention.

Titanium-induced arthropathy associated with polyethylene-metal separation after total joint replacement.

Complications of total joint replacements are not infrequent. The authors describe five patients with displacement of the polyethylene component in two knee (metal-backed patellar component) and three hip joint replacements. Clinical, radiographic, surgical, and pathologic findings were reviewed in all cases. Conventional radiographs revealed abnormal position of the metal components in all patients and opaque curvilinear periarticular deposits in four. Arthropathy caused by deposition of small titanium particles from metal friction (in the absence of interposed polyethylene) was pathologically proved to correspond to the periarticular opacity. The subtle radiolucent polyethylene component was identified in all patients; adequate visualization in some cases may necessitate imaging with additional methods such as magnification, phosphor plate, and soft-tissue radiographic techniques; conventional tomography; and arthrography. Early recognition of these abnormalities in patients with painful joint replacements may allow less extensive surgical revision and prevent development of titanium-induced arthropathy.

Somatosensory-evoked potential monitored during total hip arthroplasty.

One hundred consecutive patients were monitored using somatosensory-evoked potential (SEP) monitoring to detect intraoperative sciatic nerve compromise during total hip arthroplasty. The peroneal nerve was stimulated using the contralateral extremity to rule out systemic influences on the SEP tracings. Loss of amplitude or an increase in latency of greater than 10% was considered significant. Of the 18 patients who exhibited changes that met these criteria, 16 were female. Two patients had loss of amplitude of the tracings at the time of closure, and both of these patients exhibited postoperative sciatic nerve palsies. There were no false negatives. Femoral reaming and reduction are the surgical events most commonly associated with nerve reactions. Patients who have had prior hip procedures appear to be at higher risk. There was no correlation with intraoperative SEP changes and age, weight, surgical approach, or leg lengthening. Compared with unmonitored patients, there was no reduction in the incidence of sciatic palsy.

Association of preoperative hip motion and sciatic nerve palsy following total hip arthroplasty.

This retrospective study investigated the possible correlation between preoperative hip range of motion (ROM) and postoperative sciatic nerve palsy. From 1971 to 1987, 12 patients with partial sciatic nerve palsies subsequent to total hip arthroplasty (THA) without known etiologies were identified. During this same period a random sample of 340 patients with 373 palsy-free THAs were also identified. To exclude possible bias from revision patients (revision procedures are reported to have an increased incidence of postoperative nerve palsies), the patients were divided into three groups: (1) all THAs; (2) primary THAs; and (3) revision THAs. The preoperative hip motions studied were flexion, abduction, adduction, internal rotation, and external rotation. Analysis of the data showed no correlation between limited ROM preoperatively and the risk of postoperative nerve palsy for any of the three groups.

Intraoperative cortical somatosensory evoked potentials for detection of sciatic neuropathy during total hip arthroplasty.

Approximately 3% of patients undergoing hip arthroplasty develop postoperative sciatic neuropathy. The factors associated with changes in somatosensory evoked potentials (SSEP) and sciatic neuropathy were examined in patients undergoing hip arthroplasty, to evaluate whether the use of intraoperative SSEP could help reduce the incidence of postoperative sciatic neuropathy. Eighty-eight patients were assigned to either monitored or unmonitored groups. SSEP were recorded following peroneal nerve stimulation, using contralateral stimulation to detect systemic influences on SSEP. Amplitude reduction of less than 50% of control and/or latency increase of greater than 10% of control was considered significant, and surgical intervention was attempted to restore SSEP. Previous surgery and a lateral incision approach tended to be associated with sciatic neuropathy (p less than 0.053). The incidence of sciatic neuropathy in the monitored group (4.3%) was not different from the unmonitored group (2.4%). Isolated reduction in amplitude or prolongation in latency of the SSEP was not predictive of postoperative neurologic function of the sciatic nerve. Six patients, two of whom developed sciatic neuropathy, demonstrated complete flattening of the SSEP. Both of these patients had flattened SSEP for two or more surgical events (p less than 0.01) and flattened SSEP were present at the end of the surgical procedure. There were no false-negative SSEP changes. Simultaneous amplitude and latency changes appear to be predictive of sciatic nerve function following hip arthroplasty.

Posterior fracture-dislocation of the shoulder treated by a Neer hemiarthroplasty with a posterior surgical approach.

A 75-year-old man sustained a posterior dislocation of the shoulder associated with a completely displaced fracture through the anatomical neck of the humerus. The patient was treated successfully by a Neer hemiarthroplasty inserted through a posterior surgical approach. The posterior approach was selected because the usual anterior approach would have been complicated because of interference with a cardiac pacemaker situated in the deltopectoral region of the involved shoulder.

Radiographic classification of ankle injuries.

The initial ankle radiographs of 144 patients with ankle injuries were used to predict the total extent of ankle injury. Using the operative, clinical and radiographic findings, each injury was then classified according to the Lauge-Hansen system. Three patterns of lateral mallecolar fracture were unique to specific mechanisms of injury, with transverse fractures occurring in supination-adduction injuries, spiral fractures in supination lateral rotation injuries, and bending fractures in pronation abduction injuries. Vertical medial mallecolar fractures occurred only with supination-adduction injuries. Oblique and transverse medial malleolar fractures were not characteristic of a particular mechanism of injury. The complete extent of injury was accurately determined by the ankle radiographs in all but four patients. In these, the deltoid ligament tears could not be predicted by the radiographic findings.

Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions).

Forty-nine Monteggia and forty-seven Galeazzi lesions were treated over a twenty-five-year period. I used Bado's criteria to evaluate the results in the Monteggia lesions. In all of the children in the series either closed or open reduction yielded good results, while the results of treatment of the Monteggia fractures in the adults in the study varied. The best results were obtained in Type-I lesions treated by open anatomical reduction, internal stabilization of the ulnar fracture, and closed reduction of the radial head. Factors leading to poor results in Type-I lesions were failure to obtain anatomical reduction of the ulna, heterotopic ossification including synostosis of the proximal parts of the radius and ulna, and persistence or recurrence of dislocation of the radial head. In patients in whom the radial head could not be reduced by closed methods, the radial head was buttonholed through the joint capsule and the annular ligament was displaced but not ruptured. I have not found that reconstruction of the annular ligament is necessary in the treatment of acute Monteggia fractures. In the Type-II, III, and IV lesions in this series, fair results were the rule. The results of closed reduction of the classic Galeazzi fractures in the adults in this series were not good, due to malunion of the radius and persistent derangement of the distal radio-ulnar joint. The seventeen patients who were treated with accurate reduction and internal fixation of the fractured radius and immobilization of the forearm in full supination for six to eight weeks obtained good results.

Problems in the diagnosis and treatment of ankle injuries.

This paper discusses some of the problems encountered in the diagnosis and treatment of 371 ankle fractures treated at the University of Kansas Medical Center over a 14-year period, 1965-1979. Seven of these injuries required major reconstructive procedures after failure of initial treatment and 11 fractures required eventual ankle arthrodesis. The causes of failures of the initial treatment of these 18 cases are discussed. The extent of involvement of the articular surface of the tibia as seen on the original post-injury roentgenogram correlated closely with the extent of subsequent ankle arthrosis. The second most important prognostic feature was recognition or failure to recognize rupture of the distal tibio-fibular syndesmosis, its reduction, and maintenance of reduction until complete healing had occurred. The importance of stabilization of the fibula, maintaining its anatomic length, is emphasized. Closed reductions were as successful as open reductions and internal fixation only when reduction was accurate and maintained until healing was complete. Extensive injuries, particularly the Dupuytren and pilon fractures, are best treated by open reduction and internal fixation. The surgical techniques are demanding and technical errors must be avoided if optimal results are to be achieved.

Treatment of non-unions of fractures of the tibial diaphysis by posterolateral cortical cancellous bone-grafting.

A series of forty-four consecutive tibial diaphyseal fractures with non-unions were treated over a thirteen-year period (1965 to 1978). The majority of these injuries were complicated by severe soft-tissue damage, segmental bone loss, or infection, and multiple previous operative attempts had been made to obtain union. Cortical cancellous bone grafts were inserted posterolaterally and union was obtained in all but one fracture. Two bone-grafting procedures each were needed in three patients. Good to excellent functional results were obtained in forty-three of the forty-four involved extremities.

Limb length discrepancy and related problems following total hip joint replacement.

Limb lengthening is not uncommon after total hip replacement and may cause subjective problems for patients. We have studied 150 total hip replacements to investigate the operative change in limb length. A radiologic evaluation is used and is shown to be accurate. One hundred forty-four limbs were lengthened an average of 15.9 mm. Slightly less lengthening was observed if the greater trochanter was removed as part of the operative procedure. For subjective complaints 40 (27%) patients required heel lifts on the unoperated side to gain a satisfactory gait pattern. Partial sciatic nerve palsies also occurred in this series (3.3%) subsequent to total hip replacements. These palsies did not correlate with sex, lengthening of the extremity, or operative procedure, but did correlate with repeat surgeries and in all instances the condition resolved or improved.

Intracortical and subperiosteal lesion of unknown etiology.

A painful intracortical and subperiosteal lesion of the fibula with a 14 year follow-up is reported to regress to a painfree state. Infection is favored in the differential diagnosis. Biopsy with histological and radiographical correlation are essential for exclusion of: osteoid osteoma, osteoblastoma, periostitis, glomus tumor, eosinophilic granuloma, enostosis, hemangioma of bone, giant cell tumor, simple cyst, aneurysmal bone cyst, non-ossifying fibroma, polyostotic fibrous dysplasia, hyperparathyroidism, Paget's disease, localized area of avascular necrosis, stress fracture and even metastatic disease.

Osteoid osteoma and osteoblastoma. Similar histologic lesions with different natural histories.

A study of 9 new cases of osteoid osteoma and 3 new cases of osteoblastoma demonstrated very similar histologic findings. Both lesions were extremely vascular and frequently showed areas with histologic features of an aneurysmal bone cyst. Differentiation between the 2 lesions often depended on their clinical features and radiographic appearances. A review of 851 osteoid osteomas and 181 osteoblastomas from the literature supported a difference, however, in the natural history of the 2 lesions with osteoid osteomas tending toward regression, and osteoblastomas tending toward progression and possible late malignant transformation. Osteoid osteomas were found to have a 4.5% recurrence rate compared with a 9.8% recurrence rate for osteoblastomas (p less than 0.01). No recurrence has ever been reported after complete en-bloc resection of either lesion and this must be considered the surgical treatment of choice for both lesions where possible. Despite apparent incomplete excisions, cures are achieved in many cases among both lesions.