The decision to salvage or amputate a severely injured limb.

The decision to salvage or amputate a severely injured limb is one of the most difficult an orthopaedic surgeon may face. The inclination to undertake heroic measures to save the limb should be tempered by the realization that doing so may lead to repeated hospitalizations, extensive complications, and a poor functional outcome. Several factors must be considered, including objective elements related to the patient's injury and physical condition and subjective considerations related to the patient's psychologic, social, and economic status. We present a framework, in the context of a case study, which may be used in deciding which patients can benefit from early amputation and review five predictive indices for limb salvage.

Histological and electron microscopic analysis of tissue response to synthetic composite bone graft in the canine.

A synthetic composite bone graft material, composed of fibrillar collagen, hydroxyapatite, and tricalcium phosphate, was evaluated in canine femoral shaft defects and compared to ungrafted defects and defects grafted with autogenous bone. The results of mechanical testing of the grafted femora in torsion at 1 year postoperatively were previously reported. This report details the histological and microscopic features of the graft sites. The results of this study suggest that the healing of the graft site is not yet complete at 1 year and that healing may be more complete in defects that received the synthetic graft as compared to ungrafted sites and autogenous bone graft. The bone tissue appears to respond to the graft particles as if they were bone particles.

Surgical treatment of stage I posterior tibial tendon dysfunction.

Nineteen patients underwent surgical synovectomy and debridement for the clinical diagnosis of stage I posterior tibial tendon (PTT) dysfunction. Stage I PTT dysfunction is characterized by pain and swelling along the medial aspect of the ankle. Fourteen patients (74%) reported complete relief of pain, 3 patients (16%) reported minor pain, and 1 patient (5%) had moderate pain, and 1 (5%) had continued severe pain. Sixteen (84%) of the patients subjectively reported being "much better" and had a return of function of the PTT, as evidenced by their ability to perform a single limb-heel-rise test. Two patients (10%) underwent subtalar arthrodesis for progressive foot deformity and continued pain. Based on these results, surgical release, tenosynovectomy, and debridement are recommended for the treatment of stage I PTT dysfunction.

Reliability of standard foot radiographic measurements.

Fifty standing dorsoplantar and lateral foot radiographs were obtained on a consecutive series of patients seen in an orthopaedic foot and ankle clinic. These radiographs were duplicated, and eight common foot measurements were made on each pair by six experienced examiners. Measurements were made in two ways: first by a subjective visual assessment, and second by quantitative evaluation made according to strictly defined criteria. All measurements were made under controlled, ideal conditions with similar high quality goniometers. The results demonstrated overall greater reliability in the quantitative methods than the non-quantitative methods. For each of the quantitative techniques, a cumulated frequency distribution of differences between examiners was calculated. The approximate 95% bounds for these measures were: hallux-metatarsophalangeal angle = 6 degrees, first intermetatarsal angle = 4 degrees, metatarsophalangeal-5 angle = 11 degrees, fourth intermetatarsal angle = 4 degrees, AP talocalcaneal angle = 20 degrees, lateral talocalcaneal angle = 12 degrees, sesamoid station = 2 grades, and forefoot width = 5 mm. Physicians using these parameters to make decisions regarding patient care and clinical outcomes need to keep in mind these potential errors in making foot radiographic measurements.

Torsional properties of healed canine diaphyseal defects grafted with a fibrillar collagen and hydroxyapatite/tricalcium phosphate composite.

The need for alternatives to autogenous bone grafts is widely recognized. This study compared the torsional strength of canine femora 1 year after grafting with one of three forms of a collagen/hydroxyapatite/tricalcium phosphate bone grafting material (COLLAGRAFTTM), autogenous bone, or no graft. The groups were compared to each other and to the unoperated contralateral femora. Results of torsional testing were evaluated for torsional strength, torsional displacement, total energy to fracture and White fracture mode. Data analysis showed lower torsional strength of the operated vs. unoperated femora with the exception of morsellized COLLAGRAFTTM material, which had higher strength. However, the only difference in the operated groups was that the morsellized COLLAGRAFTTM had greater strength than several groups including the autogenous bone group. There was no difference found in angular displacement between any of the groups. However, there was a difference in the energy to fracture in both strip forms of the COLLAGRAFTTM. The final conclusion is that in this model, grafting with COLLAGRAFTTM provided torsional properties at one year postoperatively at least equivalent to autogenous bone.

The Rochester bone trephine for small joint arthrodesis in the foot.

The Rochester bone trephine is a useful instrument for performing small joint arthrodesis in the foot. The technique involves harvesting a dowel graft from the iliac crest and then inserting the graft into a recipient bed across the small joints in the foot. Minimal surgical trauma and patient discomfort result from this technique. Three cases are presented to illustrate the usefulness and diversity of this system.

Sprained ankles as they relate to the basketball player.

Concepts based on newer medical information concerning ankle injuries have changed in recent years. With these changing concepts, the method of treatment has also changed. It is the purpose of this article to review some of the commonly known information concerning ankle sprains, to emphasize the association of subtalar injury with the ankle sprain complex, to outline new information concerning the static stabilizers on the lateral aspect of the ankle, and finally, to utilize this information in producing a rationale for a new type of surgical treatment for chronic instability of the ankle.

Tire explosion injuries.

Twenty-five patients hospitalized with injuries sustained from tire explosions from 1980 to 1987 were reviewed. Injuries occurred directly from the tire rim or parts of its assembly, from the patient being thrown against adjacent unyielding structures, or a combination of these. Lethal or life-threatening injuries do occur, so these patients initially must be triaged as polytrauma patients. Resuscitation and expeditious attention to life-threatening injuries must be provided when necessary. Serious head, facial, eye, and upper extremity injuries occurred frequently. Pelvic and long-bone fractures, particularly those of the femur, are stabilized primarily as part of the overall treatment of the polytraumatized patient. Open fractures and fractures with arterial injuries and/or compartment syndromes are primarily decompressed, debrided, and appropriately stabilized. After life-threatening and limb-threatening injuries are attended, eye injuries that threaten sight should be addressed. While hand, wrist, and other upper extremity injuries that do not fall in the above categories may not require immediate or primary treatment, they are often critical in determining the patient's final outcome. This is particularly true since most patients are manual workers, often mechanics. Therefore, hand, wrist, and upper extremity injuries should be treated as early as possible and in parallel with other injuries to achieve optimal results and minimize impairment, disability, and time and economic loss from work. Strong emphasis should be placed on education and safety training in preventing this severe form of civilian trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

A note on the deep abdominal reflex.

Deep abdominal reflexes were recorded electromyographically in six patients with lesions of the upper motor neuron. The responses were bilateral, usually with identical latencies which ranged from 16.5 to 25 ms. Individual variation was never greater than 2 ms. It is postulated that these bilateral responses of abdominal muscles were independent stretch reflexes and were not mediated across the midline through an intraspinal pathway.

The crossed adductor reflex in humans: an EMG study.

Crossed adductor reflexes were recorded electromyographically in ten patients with bilateral lesions of the upper motor neuron. Three of these had a femoral neuropathy. Following blows directed to either the tendon of the adductor muscle or to the medial epicondyle of the femur, large amplitude responses of short latency and large amplitude responses of long latency were recorded from the contralateral adductor. The responses of short latency which were recorded from the ipsilateral and contralateral adductor muscles ranged from 18 to 27 ms. The contralateral responses of long latency ranged from 60 to 67 ms. On tapping the patella or patellar tendon, large amplitude responses of short latency were recorded from the contralateral adductor muscles while the ipsilateral adductor responses were absent. These responses resulted from stretch of the ipsilateral and contralateral adductor muscles. The contralateral responses were mediated across from the midline by an extraspinal mechanical pathway.

Spinal myoclonus with vacuolar degeneration of anterior horn cells.

Myoclonic contractions of muscles in the abdominal wall and lower extremities developed in a 47-year-old paraplegic woman. The spinal cord was compressed from T-3 to T-8 by an extradural renal cell carcinoma metastasis. To our knowledge, previous studies of patients with sinal myoclonus have not reported a pathologic correlation. In our patient, a focal morphologic change that consisted of vacuolar degeneration and chromatolysis of anterior horn cells was found at the levels of the spinal cord corresponding to the involved muscles. The myoclonus may be spinal in origin and due to an increased excitability of anterior horn cells during the period of sublethal injury.

Cranial nerve involvement in systemic sclerosis (scleroderma): a report of 10 cases.

Ten patients with the diagnosis of systemic sclerosis developed cranial nerve involvement. A trigeminal sensory neuropathy evolved insidiously in all patients and in five of these it was a presenting complaint. The glossopharyngeal nerve was involved in one patient. Taste was impaired in one patient and a unilateral loss of taste with fasciculations of the tongue were noted in another. Tinnitus was a complaint in three patients, two of whom had bilateral impairment of hearing. Facial weakness was noted in five patients. In three, this weakness was bilateral, while in the others the weakness was unilateral, and a past history of acute onset was obtained. The microangiopathy of systemic sclerosis is felt to be primarily responsible for these neurological deficits. The deposition of fibrous tissue may be a secondary phenomenon and contribute to the process by compression of nerves.

Peripheral nerve involvement in spinal cord injury: an electromyographic study.

This electromyographic study was undertaken to assess the peripheral nervous system in patients with various types of paraplegia. Twelve patients were studied. In 8 patients the paraplegia was of the spastic type while 4 had flaccid paraplegia. Electromyographic abnormalities consisting of denervation potentials, slowed conduction and inexcitability of nerve were demonstrated in the lower limbs of all patients. These findings suggest a diffuse neuropathy of unknown cause, although local pressure palsies may have occurred in some patients. Because this involvement was more apparent in the flaccid group of paraplegic patients as compared with the spastic one, it is concluded that the peripheral nervous system plays an important role in determining the type of paraplegia that develops following complete spinal cord lesions.