Is the central nervous system a causative factor in idiopathic scoliosis?

The present study was designed to investigate the involvement of central nervous system (CNS) in the pathogenesis of idiopathic scoliosis. Seventeen female patients with right thoracic idiopathic scoliosis (mean age = 13.36y) and ten normal controls (mean age =12.6y) entered the study. Magnetic stimulation of the brain was performed. Threshold measurements included upper (UT) and lower threshold (LT). Cortical latencies of MEPs during muscle activation were also measured.

Behaviour of an artery enclosed within a normal or hypertrophic callus of a long-bone fracture.

The behaviour of the brachial artery enclosed in a hypertrophic or a normal callus was investigated in experimentally produced fractures of the humerus in 22 dogs. The brachial artery was displaced in a bony groove created at the fractured ends of the bone. The fracture was immobilized with a metal plate and four screws. The progress of the callus formation was studied and the patency of the artery was evaluated. In 15 out of the 22 animals a medium-sized or hypertrophic callus had developed that engulfed the brachial artery without obstructing its lumen and blood flow. In five dogs the fracture site was infected and the resultant osteomyelitis obstructed the artery. In the remaining two dogs the arterial lumen was extremely narrowed, due to breaking of the plate and formation of pseudarthrosis in one and injury of the artery in the other. Unless complicated by infection resulting in vascular occlusion, callus at the fracture site may engulf an artery without interference in its patency and blood flow. The possible involvement of a functioning artery within a callus or a mass of heterotopic ossification (myositis ossificans) should be kept in mind during surgical treatment of old fractures, hypertrophic callus with pseudarthrosis or extensive heterotopic ossification.

Segmental spinal correction of idiopathic scoliosis. Luque rods and Hartshill rectangle in 30 patients followed for 2-6 years.

30 patients with idiopathic scoliosis were treated by posterior spinal arthrodesis using the Luque (8 patients) and Hartshill (22 patients) rodding systems with sublaminar segmental wiring. Patients were followed for 2 to 6 years. In most cases, postoperative correction exceeded safety correction limits (lateral bending film plus 10 degrees). Final correction was 55%, while derotation was not significant (average 3 degrees). No neurological deficit was noted. Postoperative bracing was not applied and there was 1 patient with broken rods (Luque trolley system without fusion) and 1 patient with broken wires in 4 segments. Allogenic blood transfusion was avoided in 19 patients by preoperative donation of autologous blood, in combination with salvage of intraoperative shed blood. We found segmental spinal wiring with either rods or rectangles to be a safe method for correction of scoliosis in experienced hands. It offered satisfactory stability and fusion rate with no need for external support.

A double blind study of intranasal calcitonin for established postmenopausal osteoporosis.

Intranasal administration of calcitonin (CT) avoids the problem of daily injections in the long-term treatment of osteoporosis. We examined the effect of nasal CT on bone and calcium metabolism in postmenopausal osteoporotic women in a double-blind design. 46 women, 55-75 years in age, and in good general health were included in the study. All patients were at least 6 months postmenopausal and had at least 1 vertebra fracture, bone mineral density (BMD; g/cm2) lower than 0.850 in L2-L4 in a dual energy x-ray absorptiometry (DEXA) AP view of the spine and showed biochemical indications of a fast bone loser. The patients were randomly treated with either nasal CT 200 IU per day, divided in 2 doses (n = 23) or placebo (n = 23) for 1 year. All participants received a daily calcium supplement of 1 g. Clinical and laboratory follow-up every 3 and 6 months, respectively, assessed the clinical picture, bone mineral density measured by DEXA, serum alkaline phosphatase, fasting urinary calcium, creatinine and hydroxyproline. BMD was measured in 4 sites (spine and cervical, Ward's triangle, and the trochanteric area of the hip) before treatment and after 6 and 12 months of treatment. In the placebo group, mean values at the 4 sites showed a 3.3% decrease in BMD after 6 months and a 5.0% decrease after 12 months. In contrast, the calcitonin group showed a 6.8% increase in BMD after 6 months and 11% increase after 12 months (p < or = 0.005). No patient experienced side-effects and there were no complaints of local irritation. We conclude that nasal administration of 200 IU calcitonin daily, continuously for 1 year had a positive effect on the bone mass density in osteoporotic postmenopausal women.

Total hip arthroplasty in neglected congenital dislocation of the hip.

Between 1984 and 1995, 74 total hip replacements were performed in 64 adult patients who had painful untreated congenital dislocation of the hip. The arthroplasty was performed in the position of the true acetabulum in all patients who had either high or low congenital dislocations of the hip. The femoral head was positioned in the true acetabulum after either osteotomy of the greater trochanter or shortening of the femur, or progressively using external fixation. Information was available on all patients with a followup of 1 to 11 years (mean, 7.2 years). Of the 74 replaced hips, 70 showed marked improvement concerning pain, gait, and mobility, according to the Merle D'Aubigne and Postel scale. Four hips were revised with satisfactory results. The reason for revision was infection in one case and loosening of the plastic cup in three cases. Shortening of the femur by removing a segment of bone below the level of the lesser trochanter followed by osteosynthesis without osteotomy of the greater trochanter was found to be the best method for treating bilateral and several unilateral high congenital dislocation of the hip.

Functional outcome after experimental cauda equina compression.

Spinal nerve roots often sustain compression injuries. We used a Wistar rat model of the cauda equina syndrome to investigate such injuries. Rapid transient compression of the cauda equina was produced using a balloon catheter. The results were assessed by daily neurological examination and somatosensory evoked potential (SEP) recording before surgery and ten weeks after decompression. Compression of the spinal nerves induced changes in the SEP which persisted for up to ten weeks after decompression, but it had no effect on the final neurological outcome. Our study shows the importance of early surgical decompression for cauda equina syndrome.

Humeral head torsion in recurrent anterior dislocation of the shoulder.

We measured torsion of the humeral head in 38 patients (40 shoulders) with recurrent anterior dislocation of the shoulder (RADS) and in 40 normal subjects. We found a reduced mean retroversion in the patients with RADS at 4.3 +/- 10.56 degrees (17 degrees anteversion to 32 degrees retroversion) as compared with 16.1 +/- 11.07 degrees in the control group (0 degrees to 49 degrees) (p = 0.0001). There was anteversion in 11 of the 40 shoulders in the RADS group (27.5%) and in none of the control group. The first dislocation had occurred after minimal force in 18 of 25 patients with less than 10 degrees retroversion, but in only three of 15 with over 10 degrees retroversion. We conclude that decreased retroversion of the humeral head is often associated with RADS and with first dislocation of the shoulder caused by minimal force.

The results of surgical repair of acute tears of the posterior cruciate ligament.

In 20 patients, the torn posterior cruciate ligament (PCL) was repaired without reinforcement within two weeks after injury. Fourteen patients had a midsubstance tear, and in six the ligament was avulsed from the femur without bone. There were 11 isolated and nine combined injuries. The follow-up period ranged from two to 10.5 years. Postoperatively, all had posterior instability graded from 1+ to 2+. Nevertheless, the subjective results were good in 15 patients, fair in five, and poor in none. Posterior instability did not produce significant functional impairment of the knee for a considerable number of years. Suture alone cannot restore the PCL and is not strong enough to withstand the applied forces on the knee.

Reconsideration of the Putti-Platt procedure and its mode of action in recurrent traumatic anterior dislocation of the shoulder.

The Putti-Platt procedure and its mode of action were investigated clinically and by work on anatomic specimens. The clinical work comprised 72 cases (Group A) of recurrent traumatic anterior dislocation of the shoulder operated on by the classic Putti-Platt technique from 1961 to 1985 and 92 cases (Group B) treated by the simplified operation from 1966 to 1979. Sixty-five patients from Group A and 83 (85 shoulders) from Group B were reexamined. There were two recurrences in Group A and three in Group B. In Group A, lateral rotation of the arm was restored in 19 of the 65 patients; it was increased in 44 patients by 60 degrees to 70 degrees compared with immediate postoperative rotation, which was 20 degrees to 30 degrees from the neutral position. On anatomic specimens in which the classic Putti-Platt technique was used, lateral rotation could not reach neutral without disruption of the lateral stump from the labrum. Since the lateral stump of the subscapularis is tendinous and inelastic, the postoperative increase in lateral rotation among Group A patients could be explained if the lateral stump had become gradually detached from the labrum. Therefore, it seems that this difficult part of the classic Putti-Platt procedure may be omitted, rendering the operation simpler and shorter than the original technique but just as successful.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of partial periosteal division on growth of the long bones. An experimental study in rabbits.

The mode of action of the periosteum in the growth of the long bones was investigated by comparing the activity of the growth plate after hemicircumferential and longitudinal periosteal incisions. Twenty-eight rabbits were divided into three groups. A longitudinal periosteum incision was made on the medial upper tibia in rabbits of Group A, and a hemicircumferential periosteum incision was made in Group B. An incision of the skin and superficial tissue only, similar to the skin incision of Groups A and B, was performed on rabbits in Group C. Certain differences in the development of the right tibia compared to the control side were observed in rabbits of Group B: (1) valgus deformity, 5 degrees-10 degrees; (2) overgrowth, 1-2 mm; (3) an S-shaped tibia deformity. The dynamics of the deformity support the mechanical theory because the direction of periosteum division was an important factor in the appearance of growth disturbances.

The significance of the posterior cruciate ligament in the stability of the knee. An experimental study in dogs.

The significance of the posterior cruciate ligament in the stability of the knee was investigated in dogs and it was compared with that of the anterior cruciate ligament by studying the changes produced in the knee after transection of either ligament. Osteophyte formation and changes in articular cartilage were less prominent after division of the posterior cruciate ligament. A complete longitudinal tear of the medial meniscus was found in eight out of the 10 dogs who had undergone section of the anterior cruciate but in none of the 10 with section of the posterior cruciate. It appears that, in dogs at least, the posterior cruciate ligament is less important than the anterior in the stability of the knee.

High stress fractures of the fibula.

A high stress fracture of the fibula which occurred in 48 out of a class of 120 recruits doing a difficult jumping exercise is described. No more were seen when the exercise was stopped. The importance of this report is that it confirms the theory that different muscular activities cause different stress fractures.

Solitary bone cyst of the calcaneus.

Ten cases of solitary bone cyst are presented. Nine of the lesions were asymptomatic and were discovered incidentally. Two patients were operated upon while eight were followed for 1 to 14 years. In spite of severe foot injuries that three patients have sustained, no fracture of the calcaneus occurred. We also showed experimentally that the strength of the calcaneus is not significantly reduced by the presence of the cyst. Therefore operative intervention in this lesion is not recommended. Acknowledgements: We wish to thank Dr. M. Carakostas, Consultant Orthopaedic Surgeon at Asclepeion Hospital, Athens, for allowing us to present Case 6 and Mr. St. Paipetis, Professor of the Polytechnic School of Athens, for his adivce during the experimental work.

Radial nerve enclosed in the callus of a supracondylar fracture.

At operation for the correction of cubitus varus by removal of a wedge based laterally, the radial nerve fortunately was first explored and found to run through a transverse bony tummel at the posterior level of a suprocondylar fracture sustained eight years previously. After elevation of the bony tunnel and nerve en bloc the osteotomy was completed; neurapraxia of the radial nerve soon recovered. With hindsight, the entrance and exit foramina of the tunnel could be clearly seen in the antero-posterior radiograph taken before the operation.