Acute correction and distraction osteogenesis for the malaligned and shortened lower extremity.

In limbs with combined shortening with angulation or malrotation, deformity may be quickly or slowly corrected before lengthening with external fixation. We examined a series of 35 patients with 40 limbs that underwent acute deformity correction and subsequent gradual lengthening. The average deformity corrected was 19 degrees, with subsequent average lengthening of 4.1 cm. Good radiographic callus formation was noted in 34 of the 40 segments studied. The magnitude of deformity correction had no effect on the quality of lengthened bone, incidence of complications, or the healing index. Skeletally mature segments had statistically significant decreased bone formation (p = 0.001), increased prevalence of callus complications (p = 0.001), and a higher healing index (p = 0.003). Based on this experience, it is our conclusion that immediate correction and lengthening is suitable in children and adolescents who have malaligned and shortened lower extremities. Because of poorer results in older patients, we believe that other techniques should be considered in adults.

Surgically curable hypophosphatemic rickets. Diagnosis and management.

Childhood hypophosphatemic rickets (HR) is most often caused by a defect in renal tubular resorption of filtered phosphorus. However, HR can also be caused by secretion of a phosphaturetic factor from a tumor. The presentation of patients with the different HR syndromes may be identical. Distinguishing between the HR syndromes is essential, however, because HR caused by renal defect requires life-long therapy with Vitamin D and phosphate replacement, but tumor-associated HR is cured by removal of the tumor. A case of hemangiopericytoma occurring in bone and causing HR is reported. Children with HR typically have normal levels of serum calcium and parathyroid hormone but very low levels of serum phosphorus. In a child with HR, the following features should prompt a thorough evaluation for a causative tumor: lack of other family members who have hypophosphatemia; presence of aminoaciduria, particularly glycinuria. Causative lesions are most commonly found in the bone or skin.

Effects of exogenous growth hormone on growth plate cartilage in rats.

Slipped capital femoral epiphysis (SCFE) occurs with greater frequency in children with growth hormone deficiency than in children in the general population. This epidemiologic observation suggests that SCFE may be a complication of growth hormone deficiency, associated pituitary hormone deficiencies, growth hormone therapy, or a combination of these factors. To clarify the relationship of growth hormone treatment to SCFE, homologous growth hormone was administered to rats that were without growth hormone deficiency. This treatment was found to alter the material properties of the growth plate, increasing material stiffness and decreasing specific energy-absorptive capacity. Such material changes render the growth plate more susceptible to injury or separation. The observed effects of growth hormone on the growth plates of intact animals suggest that children without growth hormone deficiency who are treated with growth hormone may be at increased risk for growth plate separation. The experimental data also indicate that growth hormone treatment of children with this deficiency may contribute to the observed increased frequency of SCFE among these patients.

Computed tomography in the evaluation of partial growth plate arrest in children.

The radiologic evaluation of growth plate injuries is vital to the surgical management of children with partial growth plate arrests. Plain film radiographs are of limited value, and in some cases, even high quality tomography does not provide adequate detail. Computed tomography (CT) can however provide a cross-sectional display and may also aid in defining the relative position of bone and cartilage in the affected area. This may prove invaluable to the surgeon in the planning of his operation. The vast majority of cases of partial growth arrest can be adequately examined by conventional means, but CT can provide additional information in cases where plain film examination is inadequate.

Distal tibial physeal fractures in children that may require open reduction.

Fractures of the distal end of the tibia in children often involve the physis. They are of particular importance because partial growth arrest can occur and result in angular deformity, limb-length discrepancy, or incongruity of the joint surface (or a combination of these). We evaluated the cases of thirty-two children who had a fracture leading to established partial growth arrest of the distal end of the tibia. Most of this group had had a Salter-Harris Type-III or Type-IV fracture. Twenty-eight of the fractures had been treated by gentle closed reduction and immobilization in a plaster cast. We also evaluated the cases of thirty-three children who were seen by us for treatment of an acute fracture; most of these were Salter-Harris Type-III or Type-IV fractures of the distal end of the tibia. Nineteen of the twenty acute Type-III or Type-IV fractures that were treated with accurate open reduction of the physis and internal fixation healed without growth disturbance, while five of the nine fractures that were treated by closed means formed a bone bridge, presaging a disturbance in growth. This study suggests that Salter-Harris Type-III and Type-IV, and perhaps Type-II, fractures of the distal end of the tibia commonly cause disturbance of growth in the tibia, and that anatomical reduction of the physis by closed or open means may decrease the incidence of these disturbances of growth, including shortening and varus angulation of the ankle.

Freeze-dried fascia lata allografts: a review of 47 cases.

Fascia lata used to connect bony structures can provide stability while maintaining mobility. Experience with reconstituted freeze-dried allogeneic fascia used in 56 patients was reviewed, including ankle, hip, and shoulder suspensions, plus ligament and tendon repairs. Follow-up was available in 47 patients with 51 fascial grafts whose ages ranged from 2 to 58 years (mean, 19.2 years). Follow-up ranged from 6 months to 16 years with a mean of 7.2 years. Results were good in 72%, fair in 20%, and poor in 8%. Allograft fascia did not stretch out with time in these cases. Preserved fascia can provide satisfactory clinical results, thus eliminating the need for collecting autogenous fascia.

Comparative clinical evaluation of freeze-dried skin allografts and autogenous gingival grafts in humans.

Freeze-dried skin (FDS) allografts and fresh autogenous free gingival grafts (FGG) were placed in five paired sites in four patients. Both types of grafts healed uneventfully. Evaluation over a 1-year period demonstrated no statistically or clinically significant differences between the FDS and FGG when: a) increase in the width of keratinized gingiva, b) decrease in recession, c) decrease in sulcus depth, k) gain in attachment level, or e) percent shrinkage of the graft were compared. It was concluded that FDS performs essentially similar to FGG in the correction of mucogingival problems, and has the advantages of decreased patient morbidity (no donor site) and availability of abundant amounts of graft material when needed.

Suspected sodium nitroprusside-induced cyanide intoxication.

Sodium nitroprusside-induced cyanide intoxication has been demonstrated in the laboratory animal and has been experienced clinically during induced hypotensive anesthesia. This is a care report of a successful resuscitation of a severe cardiovascular collapse secondary to suspected sodium nitroprusside-induced cyanide intoxication.

Evaluation of the use of freeze-dried skin allografts in the treatment of human mucogingival problems.

The purpose of this investigation was to evaluate the clinical responses to freeze-dried skin allografts when used to correct mucogingival problems in humans. FDS was obtained by the NMRI Tissue Bank after processing by standard procedures. The recipient sites were prepared using the standard partial thickness dissection with apical periosteal separation. Rehydrated FDS was sutured into place to completely cover the recipient sites. Routine postoperative procedures were performed. Evaluations were made by means of calibrated periodontal probe measurements, Kodachromes, and radiographs preoperatively and up to 12 months postoperatively. Fourteen patients received 24 FDS allografts over a total of 56 tooth sites. All treated teeth showed a substantial increase (greater than 2 mm) in the width of the zone of keratinized gingiva at all postoperative time periods (2.88 +/- 1.57 mm at 12 months). Other findings included a mean gain of attachment of 0.40 +/- 1.08 mm, a mean decrease in recession of 0.12 +/- 0.91 mm, and mean decrease in pocket depth of 0.33 +/- 0.53 mm. Patient comfort was good, and there were no untoward sequelae, even in patients receiving multiple grafts. This study indicates that FDS allografts are an acceptable and beneficial material for treatment of mucogingival problems in humans.

Solitary unicameral bone cyst: treatment with freeze-dried crushed cortical-bone allograft. A review of one hundred and forty-four cases.

One hundred and forty-four solitary bone cysts were treated by curettage and packing with freeze-dried crushed cortical-bone allograft. One hundred and eight healed primarily. There was a higher rate of recurrence in young patients (less than ten years old), in active cysts, in females, and in incompletely packed cysts. However, of the cysts that were completely packed, 88 per cent healed. These data show that freeze-dried allogeneic crushed cortical bone is superior to similiarly processed cancellous bone and gives results similar to those achieved with fresh autogenous cancellous bone. Orthopaedic surgeons should therefore consider the use of freeze-dried allogeneic crushed cortical bone instead of autogenous grafts to avoid the morbidity and increased risk of complications associated with the procedure to obtain the autogenous bone.

Clinical evaluation of freeze-dried bone allografts in periodontal osseous defects.

Freeze-dried cortical bone allografts of a fine particle size were implanted into wide three-wall, two-wall, one-wall, combination, and furcation defects. Of the 97 defects treated, 23 manifested complete bone regeneration; 39 showed greater than 50%; and 24, less than 50% osseous repair. Twelve defects failed to demonstrate any bony regeneration, of which nine were furcation involvements. From the preliminary data available, there is strong evidence which indicates that freeze-dried bone allografts have definite potential as grafting material in certain periodontal osseous defects. However, final determination must await the outcome of a larger number of cases and also histologic evidence.