Changes in growth factor levels in human wound fluid.

BACKGROUND: It has been suggested that platelet-derived growth factor (PDGF) plays a central role in wound healing. Analysis of human wound fluid revealed the presence of PDGF AA (30 kd) and monocyte/macrophage-derived growth factor (MDGF) (12 to 14 kd) in the immediate postoperative period. METHODS: The amount of PDGF AA present was assayed by Western blot analysis. The chemotactic and mitogenic potential of purified wound fluid containing PDGF AA and MDGF was determined on a responsive cell line. The biologic activity of MDGF was assayed with a cell line that is unresponsive to the PDGF AA found in wound fluid. RESULTS: Both the concentration and the biologic activity were highest in the immediate postoperative period and declined to negligible levels by 24 hours after surgery. The chemotactic activity of MDGF was highest in the immediate postoperative period and declined during the first 24 hours in a manner similar to that of the combined PDGF AA and MDGF activity. CONCLUSIONS: These data demonstrate the changing levels of PDGF and MDGF in human wound fluid over time, supporting the cascade model of wound repair. By demonstrating that MDGF acts on cell lines unresponsive to the PDGF AA found in wound fluid, these data suggest that MDGF may also play an important role in wound healing.

The candidate's view of the orthopaedic residency selection process.

Two hundred and seventy-nine applicants for an orthopaedic residency who participated in the 1985 match program returned a questionnaire that was designed to evaluate the candidate's impression of the process of selecting a residency. The respondents requested information from an average of thirty-three programs and applied to an average of twenty-two programs. The candidates who participated in the match each ranked an average of 7.5 orthopaedic residency programs. The candidates assigned a high ranking to programs in which the morale of the staff was high and the faculty was committed to teaching. Low morale, poor treatment by people at the institution, an inadequate commitment to teaching, a disorganized day of interviews, and a program in transition were the major reasons for not ranking a program. We concluded that the process is run for the convenience of the programs, with little regard to the problems that are faced by the applicants.

Adolescent tibia vara.

Adolescent tibia vara is less common and less well described when compared to infantile tibia vara. Yet, the two share a significant number of features related to their epidemiology and histology. The two diseases differ most in their radiographic appearance. It does not, however, necessarily follow that their etiologies cannot be similar. By its epidemiology and histology, adolescent tibia vara appears to be related to repetitive trauma in the form of abnormal force directed on the medial tibial growth plate due to obesity, the adolescent growth spurt, or residual, incompletely corrected physiologic varus. Such forces may give growth plate suppression by the Heuter Volkman principle similar to what is thought to occur in infantile tibia vara. In the infant, this results in typical radiologic findings related to an epiphyseal ossification center which is cartilagenous and moldable and results in progressive medial wedging. In the adolescent, however, this ossification center is bony and, therefore, will not deform under stress. The growth plate, however, still responds with decreased growth resulting in varus deformity. Thus, adolescent tibia vara, by definition not related to trauma or infection, may in fact reflect the same pathologic process at work as in infantile tibia vara.

Treatment of impending pathological fractures of the femur with flexible intramedullary nails.

Thirty-nine patients with fifty impending pathological fractures of the femur were prophylactically stabilized with flexible intramedullary nails. Indications included lesions causing unremitting pain and either measuring greater than 2.5 cm in diameter or involving more than 50% cortical destruction. Painful lesions not meeting these radiographic criteria were also considered for prophylactic nailing if radiation therapy failed to relieve pain. Ninety-five percent of patients experienced marked pain relief after nailing, and 92% were ambulatory with or without assistive devices at discharge. Complications included one fracture at the nail insertion site and three cases with nondisabling knee pain. There were no infections.

The "value" of functional independence measure scores.

Functional independence measure (FIM) scores are frequently used as if the various sections are of equal importance and as if the interval between each score is equal. We tested this hypothesis by using marketing research techniques to assess the value to rehabilitation nurses and therapists of four of the six sections. Communication was valued more highly than continence, mobility and self care in that order. The interval between the scores is not equal, with difference between a FIM 2 and 3 being greater than between a FIM 5 and 6. However, when the other difficulties such as interexaminer reliability are considered, these score differences are not great. We concluded that for practical purposes FIM scores may be used as if they were of equal interval spacing, and the scores of the various sections may be added together.

Pattern of closure of the proximal femoral and tibial epiphyses in man.

Review of 25 proximal femora and 10 proximal tibiae of adolescent skeletons at the time of plate union reveals a distinct pattern of closure. The proximal femur initiates union superiorly with closure proceeding inferiorly. Closure of the tibia occurs along the anteromedial border and spreads posteriorly. No exceptions to these patterns were encountered. A knowledge of the pattern of plate union is useful when assessing fracture geometry in the injured adolescent and in trying to understand disorders of plate closure.

Pitfalls in the assessment of skeletal immaturity: an anthropologic case study.

Nonoperative treatment protocols in adolescent scoliosis require that growth is still occurring. The open iliac apophyses and vertebral ring apophyses are usually considered evidence that growth remains. Studies of adolescent skeletons are not consistent with this view, and one such example is presented. Of clinical importance is that determinant of immaturity should be based on the secondary sexual characteristics, not roentgenographic shadows.

Moral decisions regarding innovation. The case method.

Little consideration has been given to the ethics of innovation in surgery despite the major role of innovation in orthopaedic practice. We propose that a series of cases of increasing ethical complexity may serve as a classification system and assist orthopaedists in thinking about the ethical dimensions of other cases.

Tibial tuberosity avulsion fracture in adolescents.

Avulsion fracture of the tibial tubercle is an uncommon but severe injury of the proximal tibial physis in adolescents. These fractures are all Salter Type III injuries. The fracture line may extend through the proximal tibial articular surface. When accurate reduction and sound fixation is achieved, uncomplicated union without deformity may be expected. Eight cases of tibial tubercle avulsion fracture have been treated during the last 5 years. Postinjury follow-up ranged from 18 months to 5 1/2 years. All patients were functioning well at the time of reexamination. Five of eight injuries were treated with open reduction and internal fixation. When the proximal tibial articular surface was involved in the fracture, anatomic reduction was the primary goal. This review demonstrates that this particular epiphyseal plate injury in the adolescent knee heals well without deformity or functional loss once adequate reduction and fixation of the fracture fragments have been achieved.

Conversion reactions in pediatric athletes.

We report five children and adolescents who displayed a conversion reaction in response to stresses induced by athletic competition. Failure to make proper diagnosis led to additional physician referral, needless testing, rehabilitation, or orthotic management. Patients are characterized as high achievers who are frequently younger than peers in the sport. Conversation between child and physician identified the source of conflict in four patients. Physical therapy helps resolve symptoms associated with an acute episode and facilitates transition into psychotherapy. Psychotherapy is recommended only for patients with persistent maladaptive behavior.

The epidemiology of "schooliosis".

Questionnaires submitted to children subsequent to school screening for scoliosis reveal that 13% of respondents recall being referred to a physician. This rate is considerably higher than the 3% referral rate reported by school health officials. The discrepancy points to misperceptions by students and their parents as a likely cause of "schooliosis, " a condition which brings a flood of normal children into the offices of orthopaedists and pediatricians. Correcting possible communications problems, rather than blaming the screening program, should ease the over-referral phenomenon and allow screening to continue at its present efficient levels.

Osteomyelitis of the great toe secondary to phlebotomy.

A premature infant developed Staphylococcus osteomyelitis secondary to multiple punctures of the great toe for drawing blood. The infection responded well to antibiotic therapy.

The stresses of the surgical residency.

UNLABELLED: Concern over resident work hours prompted us to study the stress of surgical residencies and determine if the experience might be associated with an increased use of alcohol and drugs. Two hundred fifty-seven surgery residents were selected from a stratified, randomized sample of residents (n = 1728) from the AMA files and were given an eight-page self-administered questionnaire. RESULTS: Surgical residents reported very long hours and heavy duties and complained of loss of sleep and exhaustion, both of which correlated with nights on call. Despite the heavier work load, surgical residents showed no more emotional stress than other residents. Surgery residents were more likely to have used alcohol in the last month than other residents (P less than .05) but 70% had used it fewer than 10 times in the month. All surgical residents were less likely to have used marijuana, cocaine, or other drugs than were other residents. Surgical residents seem to cope well with the extreme stresses of surgery training programs; however, more research needs to be done if we are to fully understand the process for training surgeons.