Complement activation products and factors influencing phagocyte migration in synovial fluids from children with chronic arthritis.

Synovial fluids from children with chronic arthritis were examined simultaneously for the presence of complement activation products and factors affecting phagocyte migration. The concentrations of C3a and C5a, but not C4a, were found to be elevated relative to normal plasma. However, the C3a and C5a concentrations in synovial fluid did not correlate with C1q binding values or with degree of migration inhibition or chemoattraction caused by that fluid. Although this data implies complement activation occurs in inflamed joints in juvenile arthritis, the specific role of immune complexes remains unproven.

Operative anatomy of nerves encountered in the lateral approach to the distal part of the fibula.

We dissected fifty legs from twenty-six cadavera to determine the origin and frequency of nerves that crossed the line of a lateral approach to the distal part of the fibula. A branch of the sural or common peroneal nerve, or both, that was at least one millimeter in diameter crossed the line of the operative approach in eleven legs (22 per cent) and was within five millimeters of the anterolateral border of the fibula in twenty-seven legs (54 per cent). We recommend that a meticulous operative technique be used during exposure of the distal part of the fibula to prevent paresthesias or painful neuromas resulting from the inadvertent transection of these small nerves.

Isolation and characterization of wear particles generated in patients who have had failure of a hip arthroplasty without cement.

Wear particles from thirty-five membranes obtained during revision hip-replacement operations were studied after digestion of the soft tissue with papain. The particles were isolated and were characterized with use of light and scanning electron microscopic techniques, x-ray microanalysis, and an automated particle analyzer. The mean size of the polyethylene particles was 0.5 micrometer, and the metal particles were a mean of 0.7 micrometer, as determined with scanning electron microscopy. The automated particle analyzer revealed a mean particle diameter of 0.63 micrometer (more than 90 per cent of all particles were less than 0.95 micrometer) and a mean of 1.7 billion particles per gram of tissue, compared with only 143 million per gram of tissue for the control samples. X-ray microanalysis revealed metal debris in sixteen (46 per cent) of the thirty-five membranes after digestion. Thirteen (50 per cent) of the twenty-six membranes surrounding a titanium-alloy stem contained metal particles, compared with three of the nine membranes surrounding a chromium-cobalt stem. Metal debris was present in only one of the twelve membranes surrounding a titanium-alloy stem without a porous coating, compared with twelve of the fourteen membranes surrounding a titanium-alloy stem with a porous coating. This tenfold difference in prevalence was significant (p < 0.005). On the average, the total number of particles (expressed in millions per gram of tissue) associated with the bipolar acetabular components was twice that associated with the fixed acetabular components. In addition, there was a trend toward a larger mean size of the polyethylene particles in association with the bipolar cups. Our data indicate that particulate prosthetic debris in the tissues around failed femoral components that have been inserted without cement constitutes a class of particles that are predominantly less than one micrometer in size and are present in amounts of more than one billion particles per gram of tissue. Routine histological methods did not detect this class of wear debris and led to a gross underestimation of the amount of debris in these membranes.

Primary internal fixation of carpal navicular fractures in the athlete.

Primary open reduction and internal fixation is an established procedure for treatment of carpal navicular fractures. With the use of an alignment device, the surgery can be performed on outpatients, under local anesthesia, in 30 to 45 min. The wrist is splinted in a protective device for approximately 6 weeks but no cast is necessary. Four of 13 patients in this series have been athletes. The procedure has allowed them to participate in sports during the healing period and to return to contact sports 6 to 8 weeks postoperatively without joint protection. These athletes have regained full range of motion in the wrist joint. Although the procedure is not recommended for hairline fractures which usually heal quickly or comminuted fractures of the navicular, it appears to be the treatment of choice for fractures of the carpal navicular bone at the level of the middle and proximal third of the bone or any displaced fragment with malposition in the axial or rotary plane.

Treatment of the upper limb in Charcot-Marie-Tooth disease.

Even though Charcot-Marie-Tooth (CMT) disease is seen frequently, relatively little has been written about the successful treatment of upper limb involvement using tendon transfers. It appears that there are several types of CMT disease and there is extreme variability in the clinical symptoms. The results of treatment were assessed by looking at four specific areas of hand function: decreased conduction velocity of the nerves, lack of opposition, weak pinch, and clawing of the fingers. A plan has been developed for tendon transfers that has worked well in clinical practice.

Treatment of nonunions of the scaphoid with the Ender compression blade plate system.

A relatively high failure rate is associated with bone grafting with or without screw fixation in scaphoid nonunions. Complicating factors include avascular necrosis, cystic degeneration, and osseous size discrepancy or compromise. The Ender blade plate is suitable for adding stability in these cases, in spite of the necessity for late removal and the possibility of articular impingement. Twenty patients were treated with this technique. Nine of these patients had had previous unsuccessful attempts at nonunion repair. Nineteen had satisfactory results, but one had a persistent nonunion. The use of the Ender blade plate system is applicable for treatment of these difficult cases that are not ideally suited to compression screw fixation.

Reconstructive osteotomy for malunion of the distal radius.

Common misconceptions about distal radius fractures result in undertreatment of many fractures, particularly in an active population. Loss of reduction of the fracture may cause a symptomatic malunion. Fourteen patients with an average age of 39 years (range, 21-65 years) underwent reconstructive procedures for radial malunions. The common malunion healed in a position of dorsal angulation, loss of radial inclination, and radial shortening. Ten patients had been treated by closed means, and 4 had undergone earlier surgical procedures without acceptable healing position of the fracture. Seven patients underwent a radial osteotomy alone, 5 patients had an osteotomy with an ulnar leveling procedure, and 2 patients had a Sauvé-Kapandji procedure alone. The average improvement in radial inclination was 14 degrees (range, 0 degrees-34 degrees), volar tilt 21 degrees (range, 2 degrees-33 degrees), and improvement in a positive ulnar variance by 6.8 mm (range, 0-48 mm). The complication rate was 29%, with a followup of 29 months (range, 12-43 months). Functional improvement was notable in 12 of 14 patients. Surgical reconstruction for malunions is technically difficult and may not completely restore the anatomy. Patient satisfaction, however, in terms of increased function, decreased pain, and decreased deformity is sufficiently high to warrant reconstructive treatment.

Preoperative templating for the equalization of leg lengths in total hip arthroplasty.

The method and results of preoperative templating for the re-establishment of leg length equality during total hip replacement (THR) are reported. The method is a modification of the technique of Müller and requires an anteroposterior radiograph of the pelvis that includes the proximal third of both femora, appropriate acetabular and femoral templates, and tracing paper. To obtain equalization of leg lengths and tissue tension, a composite drawing is made of the operative plan, with all component sizes and important measurements clearly marked. During THR, the lesser trochanter is identified and the femoral neck is osteotomized after a direct measurement is made. These principles were followed in a prospective, consecutive series of 42 primary THR procedures performed by one surgeon. All the radiographic measurements were performed by a single observer. The leg length discrepancy on the postoperative radiograph averaged 3mm (standard deviation = 3mm, range: -9 to +9mm). The postoperative clinical leg length discrepancy averaged 0mm (range: -10 to +10mm). None of the patients complained of leg length inequality. Preoperative templating allows different alternatives to be traced on paper prior to the actual surgical procedure. This method also helps determine the requirements for special prosthetic implants. Acceptable results for postoperative leg length equality may be reliably achieved using this method.