Compression-staple fixation for fractures, non-unions, and delayed unions of the carpal scaphoid.

We used the Richards scaphoid compression staple for operative fixation in a total of twenty-five patients who had a fracture of the carpal scaphoid: sixteen whom we reported on previously and nine whom we are reporting on for the first time here. In the current series, we extended the application of the method to fresh, unstable fractures (two patients) and treated an additional seven patients who had a non-union or delayed union. The procedure was simple, and no operative complications were encountered. Both patients who had a fresh fracture had a satisfactory result. Of the other twenty-three patients, only two had a result that was not satisfactory. One patient had a persistent non-union. Three patients had doubtful radiographic evidence of a persistent non-union; however, all three had a good result clinically, and only one had moderate loss of function. Although the over-all results were good, there was some worsening of the clinical results on long-term follow-up compared with those that we reported earlier. This deterioration probably was due to secondary degenerative changes in the articular surfaces.

Immunohistochemical demonstration of nociceptors in the ligamentous structures of the lumbar spine.

Substance P, a physiologically potent neuropeptide is known to participate in the sensory, and especially nociceptive, transmission of neural impulses. On histologic grounds, the nerve terminals of the sinuvertebral nerve formerly have been suggested to be sensory in character and to mediate the low-back pain syndrome. Samples of paramedullary ligamentous structures were collected on disc operations. A positive immunoreaction as an indicator of substance P was confirmed in some nerve terminals of the posterior longitudinal ligament. Neither the yellow ligament nor the intervertebral disc showed such nociceptive-type nerves.

Silver impregnation and immunohistochemical study of nerves in lumbar facet joint plical tissue.

Impingement of plical synovial tissue in a facet joint could cause pain. Plical tissue was removed during surgery for recurrent disc herniation or spinal stenosis. The presence of nerves was studied with silver impregnation, immunofluorescence, and avidin-biotin-peroxidase complex (ABC) immunostaining. Heterologous antisera to protein gene product (PGP) 9.5, substance P, calcitonin gene-related peptide (CGRP), and galanin were used to stain nerves. After silver impregnation, nerve-like structures were observed perivascularly. Such nerves located close to blood vessels were also immunoreactive for PGP 9.5, a more general cytoplasmic neural marker, whereas only few perivascular small varicosities were seen with antisera to substance P and galanin and none with antiserum to CGRP. In addition, PGP-9.5-, substance-P-, and galanin-immunoreactive nerves were occasionally seen very near to fat globules. Very few peptide-immunoreactive nerve varicosities were seen with immunofluorescence, and none of the PGP-9.5-immunoreactive nerves that were observed with ABC immunostaining were immunoreactive for neuropeptides as well. One mechanism for pain production could be mechanical compression of fatty tissue, but it is considered more likely that nerves in this particular tissue are mainly involved in local vasoregulation and that they are not sensory nociceptive nerves.

Straight leg raising test and lumbar cerebrospinal fluid levels of vasoactive intestinal polypeptide and somatostatin in patients with low back pain.

STUDY DESIGN: Straight leg raising was recorded before myelography in 77 patients. At myelography, samples of cerebrospinal fluid were drawn and later analyzed for neuropeptides vasoactive intestinal polypeptide and somatostatin. OBJECTIVES: The study sought to examine correlations, if any, between a positive straight leg raising test and cerebrospinal fluid neuropeptide levels. METHODS: The straight leg raising test was recorded for all patients before a myelography examination was performed because of intractable leg pain symptoms. Forty-seven of the patients were men and 30 were women. Cerebrospinal fluid samples were obtained from all patients upon myelography. Levels of the neuropeptides vasoactive intestinal polypeptide and somatostatin were analyzed in a blind manner by radioimmunoassay, using commercially available radioimmunoassay kits. RESULTS: The results are compatible with previous observations that suggest cerebrospinal neuropeptide levels are altered in conjunction with neural injury or pain syndromes. In the present mixed back pain patient population, which included radicular pain symptoms due to disc herniation and lumbar stenosis, alterations in vasoactive intestinal peptide levels in particular were observed with a positive straight leg raising test. CONCLUSIONS: Nerve root injury, as suggested by a positive straight leg raising test, appears to be neurochemically linked to altered cerebrospinal fluid vasoactive intestinal peptide levels.

Immunohistochemical demonstration of subclasses of inflammatory cells and active, collagen-producing fibroblasts in the synovial plicae of lumbar facet joints.

Plical tissue removed perioperatively from lumbar facet joints was studied immunohistochemically with the avidin-biotin-peroxidase complex (ABC) method for a putative presence of various subclasses of inflammatory cells and active collagen-producing fibroblasts. These methods have previously been used successfully for demonstrating specific inflammatory cells in rheumatoid arthritic synovium and cervical ligament and for studying regeneration of connective tissue, respectively. An overt inflammatory cellular response could not be demonstrated, as B lymphocytes were totally absent and no lymphocyte activation markers, either interleukin-2 receptor or immune-response-associated Ia antigens were expressed. Most of the immunoreactive cells observed were CD11b monocytes, and even these were only scattered in the connective tissue. Occasional activated collagen-producing fibroblasts were seen, suggesting in these few cases a possible regenerative response of the collagenous tissue, maybe induced by an impingement phenomenon, as such cells are not normally seen in resting connective tissue.

Serum C-reactive protein levels after total hip and knee arthroplasty.

Any operation induces an elevation in the level of serum C-reactive protein (CRP). After hip and knee arthroplasty the maximal values are seen on the second and third postoperative days, after which the CRP decreases rapidly. There is no difference between patients with cemented or uncemented prostheses. Major postoperative complications may cause a further increase in CRP levels at one and two weeks.

Long-term results of the Evans procedure for lateral instability of the ankle.

We studied the late outcome of 40 ankles (from a consecutive series of 42) treated by a modified Evans procedure. The peroneus brevis tendon was used to fashion a static tenodesis. All the patients had suffered from persistent lateral instability following an ankle sprain. The follow-up period was between nine and 12 years. Excellent or good results were achieved in 33 ankles (82.5%), three had a fair result, and four were poor. The clinical results were matched by the radiographic results which showed significant talar tilt or anterior talar translation in only three ankles. The functional result showed no positive correlation with the stress-radiographic analysis. We concluded that this modification of the Evans operation gives satisfactory long-term results, which show little change from the good results at 24 to 35 months reported in an earlier paper from our department.

The use of osteotaxis as a limb salvage procedure in severe compound injuries of the upper extremity.

Osteotaxis has been proven to offer a means for limb stabilization even in the most severe cases of upper extremity injuries, especially in cases where extensive soft tissue injuries contraindícate internal fixation or plaster cast treatment. Our policy has been to use the osteotaxis treatment only in these severe cases; we do not consider the frame to be a competing procedure with other commonly practiced modes of injury treatment. Our recent experience using the frame to salvage the function of traumatized upper extremities involves ten patients. In some of the cases there were additional carpal or cubital luxations, as well as carpal fractures. Average time in frame was eight weeks. It seems that osteotaxis offers a good means for limb function salvage in compound injuries of the upper extremity with a possibility for satisfactory result.

Osteosynthesis and allogeneic bone grafting in complex osteoporotic fractures.

Thirty patients with osteoporotic fractures were treated operatively. An allogeneic bone transplant was used in combination with a conventional osteosynthesis in each patient. The bone graft was pulverized in a bone mill and used as a substitute graft to fill the bone defect, add stability, and enhance bone union. Fractures healed without complications in 20 patients. The osteosynthesis failed in 4 patients. The fracture failed to unite in an additional 3 patients. One deep infection occurred. A biopsy taken from the allogeneic bone at plate removal after fracture union demonstrated mature bone and new bone formation. The use of pulverized allograft bone for large bone defects in patients with osteoporotic fractures yields acceptable results with no adverse effects.

Treatment of subcapital fractures of the fifth metacarpal bone: a prospective randomised comparison between functional treatment and reposition and splinting.

We did a prospective study to compare the results of treatment of subcapital fractures of the fifth metacarpal bone by closed reduction and splinting or by functional treatment. Twenty-nine consecutive patients were randomly divided into the two treatment groups (functional n = 14, and reposition and splinting n = 15). The results of treatment were satisfactory in both groups. Functionally treated patients recovered their grip force and range of movement of the affected hand a little sooner. All fractures in both groups had united within three months. There were no complications. We conclude that subcapital fractures of the fifth metacarpal bone can successfully be treated without closed reduction and splinting.

Factors affecting survival of patients with hip fractures.

The preoperative findings of 111 patients after 117 fractures of the proximal femur were recorded retrospectively. Data on survival, present type of residence and ambulatory status were analyzed. After age and sex, the presence of dementia, renal insufficiency and cardiac failure seemed to be the most important factors affecting the outcome. A full preoperative evaluation of patients with a proximal femoral fracture is needed to identify those at risk. This evaluation may help in the selection of the operative procedure.

Three cancellous bone screws versus a screw-angle plate in the treatment of Garden I and II fractures of the femoral neck.

A consecutive clinical series of 33 patients with either an undisplaced (Garden I) or minimally displaced (Garden II) femoral neck fracture was randomly divided into two operative protocols. Half of the fractures were treated with three cannulated cancellous bone screws, while the other half were treated with a standard screw-angle plate device. After a mean follow-up of 2 years, 4 patients had died, while 20 of the remaining 29 hips showed excellent or good, 3 fair and 6 poor functional results. The three-screw fixation seemed to yield more technical complications as compared to the screw-angle plate fixation. However, the differences in functional end-results were of no clear statistical significance. We conclude that the screw-angle plate device gives acceptable results in this group of fractures. The use of cannulated hip screws may be more advantageous in the treatment of dislocated femoral neck fractures, where the torsional strength of fracture fixation and femoral head viability are more critical.

[External fixation in open fractures of leg. Analysis of traps and complications of the method]. / La fixation externe dans les fractures ouvertes de jambe. Une analyse des pièges et des complications de la méthode.

A consecutive series of 51 compound tibial fractures treated by external fixation have been reviewed. All the cases whose progress was marred by complications were analysed separately. From this analysis, the following conclusions have been reached: 1. A gap at the fracture site, due to loss of bone substance or to distraction of the fragments should be treated as soon as possible by bone grafts. 2. Inadequate reduction should be corrected at the time of primary treatment. 3. Pins inserted into the region of the fracture should be repositioned early to prevent infection along the pin tracks. 4. If a sequestrum is evident, it is often necessary to remove such a focus of infection. 5. Weight-bearing, whenever feasible, should be started as soon as possible. A patellar-tendon-bearing orthosis or unilateral semi-elastic external fixation are possible satisfactory solutions in this respect. 6. When the fracture site is infected and contains necrotic fragments, the superiority of external fixation over internal fixation is obvious. The method makes it possible to stabilise the fragments without interfering with local healing and allows the exposed bone to be covered in a stable environment. Because of this analysis of the complications and pitfalls of external fixation, we have been able to put forward a regimen of treatment that may improve results.

Hip arthroplasty for alkaptonuric ochronosis. A case report.

Ochronotic arthropathy is present in about one third of the patients with alkaptonuria. The large joints, as well as the spinal column, are affected. In a typical case with a grave classic ochronotic arthro- and spondylopathy, arthroplasties of the hips greatly increased the patient's physical activity.

Autogenous osteoperiosteal grafts in the reconstruction of full-thickness joint surface defects.

Free, autogenous periosteal grafts from the medial metaphysis of the proximal tibia have been used to reconstruct full thickness cartilage defects of the articular surfaces of the knee joint. If there was a bone defect, it was initially filled with cancellous bone graft. The method is illustrated by six patients, three with acute traumatic patellar defects and three with local sclerotic osteochondritis of the medial femoral condyle. The latter had loose fragments unsuitable for fixation and single excision would have left a large and deep defect. The grafts have given satisfactory results, 14 to 59 months after the procedures. Clinical grading of the defects has been monitored by radiographs with arthroscopy of two knees and CT scan of one knee.

Ultrastructural changes in the rat carotid body in severe haemorrhagia.

Rat carotid bodies were studied electron microscopically after short-term severe hypovolaemia, which is known to induce a marked chemoreceptor activation in the carotid body. Altogether 84 nerve-endings in the hypovolaemic rats' carotid bodies and 91 nerve-endings in the control carotid bodies were investigated. An increased accumulation of the glomus cell granular vesicles near the synaptic specializations of the nerve-endings was observed after hypovolaemia. Moreover, a statistically significant increase in the contacts between the nerve-ending synaptic specializations and the glomus cell granular vesicles was observed after hypovolaemia. A suggestion was made that the glomus cells might act as modulating, probably inhibitory, interneurones, whose catecholamines are responsible for the inhibition.

The acetylcholinesterase reaction and catecholamine fluorescence in the glomus cells of rat carotid body.

The presence of both acetylcholinesterase reaction and glyoxylic acid-induced fluorescence of catecholamines in the same glomus cells of rat carotid body was demonstrated using combined histochemical methods. A suggestion is made that the glomus cells have both excitatory and inhibitory effects on the chemosensory nerve via acetylcholine and catecholamines, respectively.