Milch's classification of paediatric lateral condylar mass fractures: analysis of inter- and intraobserver reliability and comparison with operative findings.

This study aimed to test the usefulness and validity of two versions commonly quoted in the literature of the Milch classification of paediatric supracondylar mass fractures. Anteroposterior and lateral elbow radiographs of 10 consecutive acute paediatric lateral condylar mass fractures requiring open surgical reconstruction were presented to six observers in order to assess inter- and intraobserver reliability of both versions. Accuracy of classification was compared with intraoperative findings. Observers agreed with the operative findings in only 50% of cases. There was poor interobserver (kappa<0.2) and moderate intraobserver agreement (kappa<0.6) for both versions. Thus Milch's classification was not found to be a useful tool.

Radiological features of osteoarthritis of the acromiclavicular joint and its association with clinical symptoms.

PURPOSE: To determine whether increasing age is associated with increased radiological features of osteoarthritis of the acromioclavicular joint (ACJ) in a general population, and whether clinical symptoms correlate with radiological features. METHODS: Anteroposterior and axillary shoulder radiographs of 240 patients aged 20 to 80 years were randomly selected. The presence of stigmata of osteoarthritis of the ACJ including sclerosis, cysts, lysis, and osteophytes were recorded, and the width of the ACJ was measured. To determine the correlation between clinical symptoms and radiological features, the same radiological features were assessed for 100 further patients who had undergone either arthroscopic subacromial decompression (ASD) alone (n=50) or ASD plus ACJ excision (n=50, age-matched controls) based on clinical examination. RESULTS: Radiological features of osteoarthritis of the ACJ increased significantly with increasing age but were not related to gender or the side affected. Of the 10 features, only medial acromial sclerosis and superior clavicular osteophytes were more prevalent in patients with ASD plus ACJ excision than in those with ASD alone (p=0.016). The sensitivity, specificity, positive and negative predictive values of these features were poor. Therefore, clinical symptoms were not associated with radiological features of osteoarthritis of the ACJ. CONCLUSION: Radiological features should only be used as an adjunct in the decision to excise the ACJ. A thorough clinical examination is crucial in the assessment of ACJ pathology.

Vascularity in a new model of atrophic nonunion.

Our aim was to develop a clinically relevant model of atrophic nonunion in the rat to test the hypothesis that the vessel density of atrophic nonunion reaches that of normal healing bone, but at a later time-point. Atrophic nonunion is usually attributed to impaired blood supply and is poorly understood. We determined the number of blood vessels at the site of an osteotomy using immunolocalisation techniques in both normally healing bones and in atrophic nonunion. At one week after operation there were significantly fewer blood vessels in the nonunion group than in the healing group. By eight weeks, the number in the atrophic nonunion group had reached the same level as that in the healing group. Our findings suggest that the number of blood vessels in atrophic nonunion reaches the same level as that in healing bone, but at a later time-point. Diminished vascularity within the first three weeks, but not at a later time-point, may prevent fractures from uniting.

Human atrophic fracture non-unions are not avascular.

A small proportion of fractures progress to non-union. Non-unions are routinely classified into two groups either hypertrophic or atrophic according to their radiological appearance. It is a common preconception that non-unions with a hypertrophic appearance on X-ray are biologically active and vascular with potential to heal given the correct stable environment. Atrophic non-unions are considered to be avascular and inert and will not heal even under the correct stable environment. Non-unions are either infected or aseptic. In the present study, we tested the hypothesis that aseptic atrophic non-unions are less vascular than aseptic hypertrophic non-unions and healing fractures. Biopsies were taken from the fracture gap of patients with healing fractures, hypertrophic non-unions and atrophic non-unions. A dual labelling technique was used with antibodies against CD31 (JC70) and Collagen IV. Blood vessels were quantified using a Chalkley point eyepiece graticule. There was no statistically significant difference in the median vessel count between the three fracture groups. These findings do not support the hypothesis that established atrophic fracture non-union are less vascular than hypertrophic non-unions or healing fractures.

Growth factor expression during the development of atrophic non-union.

The aim of the study was to determine, for the first time, the distribution of expression of several important growth factors during the development of atrophic non-unions using an animal model. The sites of expression of TGFbeta, PDGF, FGFb, and BMP 2/4 were determined at the osteotomy sites of both normally healing bones and within atrophic non-unions at 1 and 8 weeks after operation using immunolocalization techniques. At 1 week after operation, the osteotomy gaps of the control group contained fracture haematoma and surrounding granulation tissue, whereas the osteotomy gaps of the non-union group contained only haematoma. The tissues of both the non-union and control groups demonstrated the same presence and distribution of growth factors. By 8 weeks after the operation, the control group osteotomy gaps were filled with bone within which the active osteoblasts stained positively for each of the growth factors. At 8 weeks, the osteotomy gaps of the non-union group contained only fibrous tissue, which failed to stain positively for any of the factors. These findings suggest that the development of atrophic non-union is not directly due to a lack of these four growth factors.

Disability and mental health of patients waiting for total hip replacement.

We performed a cross sectional study to examine the relationship between physical function and mental health of patients waiting for total hip replacement surgery, and the relationship between physical and social function and mental health to time spent waiting for surgery. We found that, in addition to the expected poor hip function, limited mobility and pain, one-quarter of the patients had clinically significant mood disorders and another quarter were in the borderline range. No association was found between severity of mental disorder and assessment of hip function. The patients had been waiting for 1-26 months (median 6 months) for surgery: yet those waiting longest were no worse on any of the outcome measures and their mental health was better. We conclude that mental disorders are common in patients waiting for hip replacements, are not directly related to hip function and their origins are unknown, but they require clinical assessment and treatment. There is no evidence that physical or social function or mental health are worse in those waiting longer for hip replacement surgery. Even so, these patients are severely disabled and some have to wait too long.

Metabolic activity of a new atrophic nonunion model in rabbits.

The aetiology of atrophic nonunions is not well understood: they are often thought to be nonreactive and metabolically inactive. Investigation of their biological processes is hampered by the lack of a useful animal model. Current models involve either wide segmental excision of the diaphysis or interposition of Silastic to impede the normal healing processes. neither of which resembles the clinical situation. We therefore aimed to establish a model of atrophic nonunion that more closely resembles the clinical situation and to use this model to evaluate the metabolic activity of the gap tissue of the nonunion. A simple and reliable model of atrophic nonunion has been developed in rabbits. It more closely represents the clinical situation by avoiding large segmental excisions and the interposition of foreign materials. Clinical, radiological, and histological data support the diagnosis of atrophic nonunion in the model. The concentration of adenosine triphosphate in the gap tissue of the nonunion served as a marker of metabolic activity. The gap tissue of established atrophic nonunions had a significantly higher concentration of adenosine triphosphate than did the control specimens. In this model, the gap tissue is metabolically active; therefore, under certain conditions, it may be possible to induce union if the correct stimulus is provided.

Anatomical effects of periosteal elevation.

Research that involves harvesting the periosteum is common. The exact technique of harvesting is rarely described; however, it may be of vital importance because techniques may vary in their ability to raise the osteogenic cambial layer, which is reported to be tightly adherent to the underlying cortex. This study was performed to define how the cambial and fibrous layers of the periosteum are affected by different techniques of stripping. The periosteum was raised from the tibia and the humerus of adult rabbits with four stripping techniques. The stripped bone surface was examined histologically and with a scanning electron microscope to determine whether the fibrous and cambial layers of the periosteum had been removed and whether there had been damage to the underlying cortex. The results from the two anatomical sites were the same. Raising the periosteum with cortical bone chips (shingling) or with a periosteal elevator removed both layers of the periosteum and caused considerable damage to the surface of the cortex. Raising the periosteum with a sharp scalpel or by simply pulling it off removed the fibrous layer but left the osteogenic layer intact adherent to the cortex. We conclude that some techniques of periosteal elevation fail to harvest the osteogenic layer and therefore may lead to unexpected experimental results. We suggest that authors describe the exact technique of periosteal stripping that was employed.

Digital metastases of giant cell rich malignant fibrous histiocytoma.

Background. Metastatic spread of soft tissue sarcomas to the digits is extremely rare and metastasis of MFH to the fingers and toes has not been documented.Purpose. We present two case reports of metastatic spread from a giant cell rich malignant fibrous histiocytoma to the digits and discuss their management.