Engelmann's disease.

A 5-year-old boy with diaphyseal dysplasia who exhibited marked involvement of the cranial bones developed marked disk edema in a one-year period. We believed the optic canal was being rapidly compromised by bony proliferation and vision was threatened. Selective bone studies, including tetracycline labeling, demonstrated a rapid accretion of bone 1 1/2 to two times the expected rate for his age. We performed bilateral unroofing of the optic canals with additional temporal decompression of the left orbit. Limited unroofing of the right eye proved to be inadequate and only with additional extensive temporal decompression was the disk edema of the left eye reversed. Tomograms taken one year after surgery revealed regrowth of bone in the optic canal and orbital roof. The usefulness of bony decompression of the orbits in Engelmann's disease is requestionable.

Camurati-Engelmann disease (progressive hereditary craniodiaphyseal dysplasia). Case report.

In a patient with Camurati-Engelmann disease, orbital and optic nerve decompression resulted in improvement of papilledema. Subsequent x-ray films of the optic canals, however, revealed reconstitution of osseous optic canals bilaterally, and papilledema has returned in one eye. Definitive treatment of this dysplastic metabolic bone disorder rests in the control of rapid abnormal bone formation.

Neuropathic spinal arthropathy. A review of the Charcot spine.

The historic, pathogenetic, and clinical aspects of neuropathic spinal arthropathy are reviewed. The disorder is characterized by biologic inflammation and repair reaction to injury. In the absence of adequate pain perception, splinting of the injured portion of the spine does not occur. Motor loss may occur. Surgical stabilization and bone grafting of the injured spine may effect correction of the kyphosis or scoliosis and permit healing of the vertebral fractures. Correction of the deformity depends on the extent of the defor pain perception, splinting of the injured portion of the spine does not occur. Motor loss may occur. Surgical stabilization and bone grafting of the injured spine may effect correction of the kyphosis or scoliosis and permit healing of the vertebral fractures. Correction of the deformity depends on extent of the deformity, the location of the lesion, and associated complicating medical disorders. A successful fusion is in no small way dependent on the desire and the ability of the patient to participate in the protracted period of postoperation care.

Magnetic Resonance Imaging of Major Ligamentous Knee Injuries.

In brief: Magnetic resonance imaging (MRI) is useful for assessment of capsuloliga-mentous and other periarticular soft-tissue structures of the knee. It is especially valuable for its ability to accurately diagnose tears of the anterior cruciate ligament (ACL). MRI findings that indicate an ACL tear include frank disruption of the ligament, waviness to the anterior margin of the ligament, and areas of heterogeneous increased signal within the ligament on sagittal T2-weighted images.

Magnetic Resonance Imaging of Osseous Lesions of the Knee.

In brief Although magnetic resonance imaging of the knee is performed primarily to assess meniscal and soft-tissue pathology, traumatic osseous lesions also may be detected with this method. These lesions include occult intraosseous fracture (a new diagnostic entity), stress fracture, and osteochondral fracture. The authors discuss specific features of magnetic resonance images that can help the physician make an accurate diagnosis.

Magnetic Resonance Imaging of Meniscal Tears.

In brief: Magnetic resonance imaging (MRI) is highly accurate for diagnosing meniscal tears. It can be performed reliably even when the patient is in acute pain and when joint effusion and hemarthrosis are present. Though it is dependent on a machine and a protocol, MRI is essentially operator-independent, unlike arthrography and arthroscopy, which rely on operator skill. MRI has the potential to improve the accuracy of arthroscopy because it can localize pathology and prompt more thorough examination of difficult areas.

Meniscus repair.

The rationale and technique for surgical repair of the meniscus of the knee are presented with a report of the results in ten cases. Contraindications to meniscus reapir include peripheral vascular disease, metabolic disorders disrupting collagen synthesis, renal disease, and "collagen-vascular" disorders. The synovium adjacent to the injured meniscus must be gently handled and preserved. Small caliber sutures should be used and totally buried so that they cannot be come intra-articular wear particles. Other necessary knee surgery can be done at the time of meniscus repair. To prevent dehiscence of the repair site and permit meniscus healing, postoperative immobilization is mandatory. Although a two-year follow-up is described in the present report, it appears that the results of the procedure might be adequately assessed at about six months.

Fracture of the distal humeral chondroepiphysis in the neonate. A case report.

A neonatal fracture-separation of the distal humeral chondroepiphysis occurred associated with a difficult footling breach delivery. The diagnosis can be predicted when a physical examination of an apparently "dislocated" elbow reveals a normal triangular relationship between the olecranon process and the medial and lateral epicondyles. The injured epiphysis tethered on a wide-based periostium. Acceptable reduction was obtained by alignment of the fracture fragments and avoidance of an abnormal varus or valgus alignment. Healing was rapid, and remodeling as well as range of motion were excellent at six months.

MR imaging of solitary osteochondromas: report of eight cases.

MR imaging was performed in eight patients with osteochondromas, and the results were compared with the histologic findings in six of these cases. MR imaging effectively showed the essential anatomic features of lesions and was particularly useful in assessing the presence and thickness of the cartilage cap. The cartilage cap was clearly seen as a region of high signal intensity on T2-weighted images. A superficial zone of low signal intensity was seen covering the cartilage cap, corresponding to an intact perichondrium, in all of the five cases in which histologic examination confirmed the presence of an intact perichondrium. The results of MR in these cases suggest that MR is useful in the preoperative planning of cases in which excision of an osteochondroma is necessary. Optimal surgical resection of the lesion requires complete excision of an intact perichondrium to prevent possible recurrence of the tumor.

Management of patellar subluxation. A modification of Hauser's technique.

Patellar subluxation is one of the most common causes of internal derangement of the knee in young individuals. Most surgical techniques mandate entrance into the knee joint and require prolonged postoperative immobilization. The result may be excessive postoperative synovitis and occasionally, hemarthrosis. Prolonged postoperative immobilization results in joint stiffness. The authors propose a modification of Hauser's technique which allows tailored correction of the abnormal vector forces applied to the patella, simple adjustment of the tension in the extensor mechanism, creates patellar stability, and permits rapid return of knee motion. A new tibial corticocancellous window is created in a manner similar to Hauser's technique. The cancellous defect is deepened by curettage and the transferred tibial tubercle is then inverted, inserted through the window, and tamped into the graft bed thereby gradually increasing tension in the tendon. The cancellous and cortical bone from the window is then tamped in behind the patella tendon, buttressing the tendon, and permitting the knee a full unguarded range of motion on the operating table. In 23 operations in 22 patients, with a follow-up of 35.4 months and a mean patient age of 18.7 years, all patellae were stable. All but one patient achieved full range of motion. Younger patients with minimal or absent preoperative patellofemoral chondromalacia had uniformly good results.

Detection of knee hyaline cartilage defects using fat-suppressed three-dimensional spoiled gradient-echo MR imaging: comparison with standard MR imaging and correlation with arthroscopy.

OBJECTIVE: A preliminary study was done to prospectively compare fat-suppressed three-dimensional spoiled gradient-echo (3D SPGR) MR imaging with standard MR imaging for detection of defects in the hyaline cartilage of the knee, using arthroscopy as the reference standard. SUBJECTS AND METHODS: We studied 43 consecutive patients referred by two orthopedic surgeons for MR imaging of the knee. Twelve had arthroscopic correlation; they formed the basis of our study. Hyaline cartilage was imaged with a fat-suppressed 3D SPGR sequence with previously determined optimal imaging parameters. Our standard MR imaging study consisted of two-dimensional coronal T1-weighted spin-echo, sagittal dual-echo T2-weighted spin-echo, and axial multiplanar gradient-echo sequences. With arthroscopy as the reference standard, sensitivity and specificity of fat-suppressed 3D SPGR and standard MR images for detecting cartilage tears were determined by articular surface (eight surfaces in each patient: medial and lateral patellar facets, trochlear facets, femoral condyles, and tibial plateaus). Statistically significant differences in sensitivity and specificity were determined. RESULTS: Arthroscopy showed 15 cartilage defects in seven patients. The fat-suppressed 3D SPGR images had higher sensitivity (93%) than the standard MR images (53%, p = .03). Specificity was 94% for the fat-suppressed 3D SPGR images compared with 93% for the standard MR images (p > .05). The five false-positive articular surfaces on fat-suppressed 3D SPGR images were from focal signal change within the substance of the cartilage without a contour defect. Smoothly contoured thinning and loss of the trilaminar appearance of the hyaline cartilage at the lateral femoral notch was shown in all subjects and was considered a normal finding. CONCLUSION: Fat-suppressed 3D SPGR imaging is more sensitive than standard MR imaging for the detection of abnormalities of the hyaline cartilage in the knee. Routine use of this technique may strengthen the role of MR imaging for noninvasive evaluation of internal derangements of the knee.

Anterior cruciate ligament tears: MR imaging compared with arthroscopy and clinical tests.

Seventy-nine magnetic resonance (MR) studies of the knee were reviewed in an evaluation of the ability of MR imaging to demonstrate arthroscopically proved anterior cruciate ligament (ACL) tears. MR findings were also compared with the findings of two commonly applied clinical tests of ACL instability: the Lachman test and the anterior drawer test. The sensitivity of MR imaging was 94% (17 of 18), compared with 78% (14 of 18) for the anterior drawer test and 89% (16 of 18) for the Lachman test. The specificity was 100% for all three. Three MR criteria were applied: irregularity or a wavy contour of the anterior margin of the ligament, high-signal-intensity change within the substance of the ligament on T2-weighted images, and discontinuity of that substance. The sagittal T2-weighted image was especially helpful, producing an "arthrographic" effect, in which the anterior margin of the ACL is outlined by high-signal-intensity joint fluid. By demonstrating ACL and other extrameniscal lesions, MR imaging may help clarify the mechanisms of knee injury.

Fat-suppressed three-dimensional spoiled gradient-echo MR imaging of hyaline cartilage defects in the knee: comparison with standard MR imaging and arthroscopy.

OBJECTIVE: The sensitivity of fat-suppressed three-dimensional spoiled gradient-echo (SPGR) images was compared with that of standard MR images for detecting hyaline cartilage defects of the knee, using arthroscopy as the standard of reference. SUBJECTS AND METHODS: We assessed 114 consecutive patients for hyaline cartilage defects of the knee with both standard MR imaging sequences and a sagittal fat-suppressed three-dimensional SPGR sequence. Of these patients, 48 with meniscal or ligament injury, or persistent symptoms, underwent subsequent arthroscopy. The standard MR images and SPGR images of these 48 patients were then retrospectively analyzed for articular defects in a blinded fashion by two independent observers. Sensitivity, specificity, and intraobserver and interobserver agreement were determined for the different imaging techniques. RESULTS: One fourth of the patients who went on to arthroscopy were shown to have isolated hyaline cartilage lesions that were clinically confused with meniscal tears and that were missed on the standard MR images. When looking at all surfaces combined for each reader, the SPGR imaging sequence had a significantly higher sensitivity than the standard MR imaging sequences for detecting hyaline cartilage defects (75-85% versus 29-38%, p < .001 for each comparison). When looking at individual surfaces for each reader, significant differences in sensitivity were shown for each surface except the trochlear and lateral tibial surfaces. We found no difference in specificity (97% versus 97%, p > .99). We also found that combined evaluation of standard MR and SPGR images gave no added diagnostic advantage (sensitivity, 86%; specificity, 97%; p > .42). Except for the lateral tibial surface, the study achieved excellent reproducibility among readings and between readers. CONCLUSION: Fat-suppressed three-dimensional SPGR imaging is more sensitive than standard MR imaging for the detection of hyaline cartilage defects of the knee.

Use of cefamandole in the treatment of soft tissue and skeletal infections.

In review of our data, 12 of 38 patients (31.5 percent) had adverse drug reactions, a somewhat bothersome factor. Disturbing side effects of leukopenia and pancytopenia were seen in two patients, respectively, who were receiving cefamandole 12 g/d. Other cephalosporins, including cephalothin and cefazolin, have been reported to cause leukopenia. Eosinophilia and elevations of alkaline phosphatase and SGOT levels were noted with other cephalosporins. We observed no adverse clinical reactions associated with these findings. Although our study was able to demonstrate the therapeutic effectiveness of cefamandole in the treatment of soft tissue and skeletal infections, it should be reemphasized that cefamandole should be used only as an alternative treatment for the penicillin-allergic patient. In reality, a first-generation cephalosporin should be used for gram-positive organisms if one is required in soft tissue infections.