Late recurrent hemarthrosis following knee arthroplasty associated with epithelioid angiosarcoma of bone.

We report a case of recurrent hemarthrosis 1 year following total knee arthroplasty in a patient with no bleeding diathesis, the hemarthrosis was found to be related to, and led to the diagnosis of high grade sarcoma of the proximal tibia. Twenty five years earlier, he sustained a lateral tibial plateau fracture and was treated with open reduction and plating. Sarcoma developing in association with a metallic orthopedic prosthesis or hardware is an uncommon, but well-recognized complication. Sarcomas that occur adjacent to orthopaedic prostheses or hardware are of varied types, but are usually osteosarcoma or malignant fibrous histiocytoma.

A comparative roentgenographic analysis of the lumbar spine in male army recruits with and without lower back pain.

AIM: To determine whether there is an association between lumbar spine radiographic findings and reported current and/or past lower back pain (LBP). MATERIALS AND METHODS: Four hundred and sixty-four age-matched (mean age 18 years+/-2 months) consecutive male army recruits were examined. Half of them had a history of episodes of LBP. An orthopaedic evaluation (including radiographs of the lumbar spine) is part of the routine medical examination for all military recruits. Two senior orthopaedic surgeons and one radiologist who performed the morphological measurements assessed the radiographs. RESULTS: We found an increased frequency of right-sided scoliosis, lumbar lordosis, sacral lumbarization, wedge vertebra, bilateral spondylolysis of L5 and/or a sagittal diameter of less than 12 mm among the recruits with LBP. No such association was found with spina bifida, left-sided scoliosis, hemi-lumbarization, sacralization and hemi-sacralization, Schmorl's nodules or mild degenerative changes. CONCLUSION: Given that radiographic screening shows that LBP is more common in those with spinal deformity it may be a reasonable means of predicting which individuals are more likely to develop LBP.

Whiplash associated disorders -- subjective complaints vs clinical and objective findings. A retrospective study of 866 patients.

The subjective complaints of 866 WAD (whiplash associated disorders) patients were recorded at a follow-up examination some 32 months after the accident. The complaints were compared to a number of relatively objective examinations -- X-ray, CT, MRI, EMG, Bone scan, and clinical assessment. Neck pain and radiating pain to the limbs were the major complaints. The big majority of the X-rays findings, both primary and late (98%), were found either non-pathological or indicating degenerative changes and old fractures. All positive CT and MRI findings not related to known degenerative changes and old fractures were considered relevant. Bone-scan and clinical findings not related to old injuries were considered to be relevant to the WAD. Positive EMG findings were considered relevant except for those related with incidental CTS. Comparing the various testing modalities, CT and EMG were found positive in 25% and 33% of the tested sample (11% and 12% of the whole WAD patients), accordingly. Bone-scan and MRI were conducted in a much smaller sample of the patients, and only 33% and 25% (3% and 2% of the whole population) were found pathologic, accordingly. Clinically, C-C (chin-chest touch) and RoM tests identified 75 (9%) and 58 (7%) of the pathologic population, accordingly. Excluding degenerative changes and incidental CTS, only 25% of the patients had any objective supporting findings.

Dynamic pressures on the diabetic foot.

A retrospective study was conducted in order to investigate the relation between increased plantar pressure and ulcers in the diabetic foot and contribute more information on this subject. Maximal plantar pressure (MPP) is reported on various areas of the plantar aspects of the feet in 328 diabetic patients and 75 healthy subjects. An increase in MPP under all plantar areas except for the heels was found to be related with increasing severity of the diabetes symptoms. There was also a significant decrease in the application of high pressures to the heels, the metatarsal heads II-IV and the toes.

Percutaneous release of trigger digits.

Twenty nine patients with 31 trigger digits were treated by percutaneous release under local anaesthesia using an 18 gauge needle. One patient was lost to follow up, and the remainder were examined at a mean follow-up of 14 months. One patient (one thumb) experienced recurrent symptoms, and required an open release. The remaining 27 patients with 29 trigger digits had complete relief of their symptoms.

Characteristic dynamic differences between healthy and low back pain subjects.

STUDY DESIGN: Open retrospective study. OBJECTIVES: To assess the functional capacity impairment of chronic low back pain (LBP) patients using characteristic dynamic changes. SETTING: Orthopaedics and Physiotherapy departments at Tel-Aviv, Israel. METHODS: Thirty-eight normal healthy volunteers and 607 chronic LBP patients were tested on a computerized 3-D lumbar dynamometer. The four major parameters measured were the maximal isometric torque (MIT), maximal velocity against 25% MIT and 50% MIT (MV25, MV50, respectively) and maximal torques in secondary axes (MST). All patients parameters were compared to the normal, healthy findings. RESULTS: All four parameters were found to be significantly different between healthy (or non-symptomatic) and symptomatic LBP subjects. CONCLUSIONS: The findings support the use of 3-D dynamometry and the four parameters mentioned to objectively classify patients with functional disability.

The use of three-dimensional computed tomography in evaluating snapping scapula syndrome.

This article evaluates imaging of the scapula and scapulothoracic joint in patients with snapping scapula syndrome. Between 1990 and 1996, a total of 20 patients (10 men and 10 women) with snapping scapula syndrome were evaluated. Diagnosis was based on patient complaints and physical examination findings. There were 26 affected scapulae (6 patients had bilateral presentation). Imaging of the scapula included plain radiography, computed tomography (CT), and 3-dimensional computed tomography (3-D CT) reconstruction. Plain radiography revealed bony incongruity between the anterior aspect of the scapula and the chest wall in 7 scapulae, CT revealed such incongruity in 19 scapulae, and 3-D CT revealed incongruity in all 26 scapulae. Treatment was conservative, consisting of nonsteroidal anti-inflammatory drugs, a physiotherapy program, and subscapular injection of a local anesthetic and steroids. In 5 patients who responded poorly to conservative treatment, the region responsible for the snapping was resected. Pain relief and resolution of the snapping were complete following surgery in 4 patients, while pain and crepitation persisted in the fifth. Three-dimensional CT is recommended as the main imaging modality in the evaluation of any patient with snapping scapula syndrome who is a candidate for surgical intervention.

Prolonged leaching time of peptide antibiotics from acrylic bone cement.

The leaching time of antibiotics in growth inhibitory concentrations from polyacrylic bone cements was determined using Escherichia coli, methicillin resistant Staphylococcus aureus, Staphylococcus epidermidis, Klebsiella pneumoniae, and Pseudomonas aeruginosa as target bacteria. The leaching time of the peptide antibiotics vancomycin and polymyxin B nonapeptide was considerably longer than that of gentamicin, novobiocin, and erythromycin. Among the nonpeptide antibiotics, the leaching time of novobiocin lasted longer than did that of gentamicin. The acylated parent polymyxin B antibiotic leached for a considerably shorter period than did the deacylated polymyxin B nonapeptide derivative, suggesting that the lipids impede the leaching process from the cement. Cement beads impregnated with polymyxin B nonapeptide and introduced into the tibia of three rabbits receiving oral novobiocin protected bone infection against a challenge of Pseudomonas aeruginosa that otherwise caused infection in tibias containing gentamicin impregnated cement beads. The peptide antibiotics alone or in combination with other antibiotics (polymyxin B nonapeptide and novobiocin) impregnated in cements for orthopaedic procedures may provide longer periods of protection against a wide range of bacterial pathogens.

Patterns of weight distribution under the metatarsal heads.

The longitudinal arch between the heel and the forefoot and the transverse arch between the first and fifth metatarsal heads, absorb shock, energy and force. A device to measure plantar pressure was used in 66 normal healthy subjects and in 294 patients with various types of foot disorder. Only 22 (3%) of a total of 720 feet, had a dynamic metatarsal arch during the stance phase of walking, and all had known abnormality. Our findings show that there is no distal transverse metatarsal arch during the stance phase. This is important for the classification and description of disorders of the foot.

Thromboxane A2 in postischemic acute compartmental syndrome.

OBJECTIVE: To evaluate whether thromboxane A2 participates in the ischemia-reperfusion injury associated with acute compartmental syndrome (ACS) and if by using a cyclooxygenase inhibitor this can be either reduced or abolished. DESIGN: To assess the role of thromboxane A2 in ACS, a tourniquet was applied for 2 hours to the hind limb of 12 dogs. Group 1 (n = 6) served as controls while group 2 (n = 6) was pretreated with lysine-acetyl-salicylate (Lysoprim). Blood thromboxane B2 levels and intracompartmental pressures were assayed prior to inflation of the tourniquet and at 5 minutes, 90 minutes, and 24, 72, and 144 hours after deflation. RESULTS: Five minutes after deflation, the compartmental pressure increased from 11.2 +/- 2.2 mm Hg to 16.1 +/- 3.3 mm Hg and 17 +/- 2.2 mm Hg (mean +/- SD) in groups 2 and 1, respectively. At 90 minutes and 24 hours, pressures were 17.1 +/- 3.3 mm Hg and 23.2 +/- 3.3 mm Hg (P<.01) and 15.3 +/- 2.6 mm Hg and 25.2 +/- 1.8 mm Hg (mean +/- SD) (P<.001), respectively, in groups 2 and 1. A similar effect, although of a lesser magnitude, was observed in the counterlateral limb. Thromboxane B2 levels increased from a mean (+/- SD) of 46 +/- 5.5 pg/0.1 mL to 132 +/- 7.5 pg/0.1 mL at 90 minutes in group 1, while remaining unchanged in group 2. CONCLUSIONS: Thromboxane A2 plays a major role in the ischemia-reperfusion injury of acute compartmental syndrome. By using a cyclooxygenase inhibitor both the levels of thromboxane and the compartmental pressures can be reduced.

'Epiphyseal dysgenesis' in Laurence-Moon-Biedl-Bardet syndrome.

Ten patients with Laurence-Moon-Biedl-Bardet syndrome were investigated. They all belonged to one large family within which several intermarriages had taken place. We found that, apart from the already described abnormalities, these patients suffered from dysgenesis of the following epiphyses: vertebrae, proximal femur, proximal tibia, capitellum, tarsal navicular, and the distal epiphysis of the first metatarsal. The degree of polydactyly, a prominent feature of this syndrome, varied from patient to patient, ranging from a wide fifth metatarsal or metacarpal to a complete sixth digit. As in other epiphyseal dysgenesis, a pseudoepiphysis of the distal first metacarpal was present. One patient (the eldest) was tetraparetic due to severe spinal stenosis.

Effect of low-power laser irradiation on the mechanical properties of bone fracture healing in rats.

BACKGROUND AND OBJECTIVE: Low-power laser irradiation (LPLI) has been found to have a positive effect on bone fracture healing in animal models, based on morphogenic, biochemical, roentgenographic, and electron microscopic measurements. We investigated the effect of LPLI on bone fracture healing in rats using biomechanical methods. STUDY DESIGN/MATERIALS AND METHODS: Two groups of male Wistar rats, divided in a randomized block design in a blinded fashion, each consisting of 25 animals, were subjected to anesthesia and tibial bone fracture with internal fixation. The first group was treated with LPLI (HeNe laser 632.8 nm, 35 mW), applied transcutaneously over 30 minutes to the area of the fracture daily for 14 days. The second group served as a control. After 4 weeks, the tibia was removed and tested at tension up to failure (by a Lloyd LR 50K testing apparatus, U.K.) in 16 rats from group I and 15 from group II. The maximal load at failure, the structural stiffness of the tibia (callus stiffness), and the extension maximal load were measured. RESULTS: The maximal load at failure and the structural stiffness of the tibia were found to be elevated significantly in the irradiated group (P = .014 and P = .0023, respectively), whereas the extension maximal load was reduced (P = .015). In addition, gross non-union was found in four fractures in the control group, compared to none in the irradiated group. CONCLUSION: These results suggest that LPLI treatment may play a role in enhancing bone healing.

Long-term antibiotic treatment in geriatric diabetic foot infection.

A case report involving a 77-year old diabetic patient with an arterial foot ulcer and subsequent osteomyelitic infection is presented. Due to the patient's ineligibility for surgical intervention, long term antibiotic treatment based upon multiple culture, bone biopsy, radiograms and isotope scanning was initiated. Complete resolution of the osteomyelitis defined by subjective as well as objective criteria was achieved after three months of antibiotic treatment. The common and atypical characteristics of the geriatric population coupled with treatment plan involving a multidisciplinary approach resulted in maintaining foot function and pain-free ambulation in this 77-year old patient.

Efficacy of closed wound drainage after total joint arthroplasty. A prospective randomized study.

The efficacy of closed suction drains following joint arthroplasty operations was prospectively evaluated in a randomized manner. All 88 patients allotted to primary knee or hip arthroplasty operations during a 6-month period were included in the study. Drains were used in 32 of 58 patients following total knee arthroplasty and in 18 of 30 total hip arthroplasties. No statistical difference was found in the hemoglobin levels measured following surgery and in the number of patients requiring blood transfusions between the two groups after total hip arthroplasty (P = .06). The power of the test to detect a difference of 2 g% in hemoglobin levels is 94%. Two patients from each group had a transient serous discharge for 3 to 4 days following surgery and none had wound infections. Significantly more blood transfusions were needed in patients with drains following total knee arthroplasty compared with patients without drains (0.7 unit per patient versus 0.2 unit per patient, P = .005) to maintain the same hemoglobin blood levels. Patients with no drains had significantly more transient sterile serous wound discharge than patients with drains (38.4% vs 12.5%, P = .02). Superficial wound infection necessitating antimicrobial medication developed in one patient with drains and in no patients in the other group. These results suggest that drains may not be needed following total hip arthroplasty. The more common serous wound discharge may be of some concern when drains are not used following total knee arthroplasty.

[Physical 3-dimensional testing of the lumbar spine using the IsoStation B-200].

Low-back pain is not only one of the major medical problems, but the most common. Up to 80% of the population is expected to experience back pain at least once in their lifetime. The functional disability caused by LBP has a major influence on quality of life, as well as its economic aspects. Psychological and social factors are highly involved with LBP. Therefore any advance in objective assessment of LBP is of major importance. We present a relatively new system used for the past 2 years by our departments, the IsoStation B-200 (Isotechnologies Co., NC). This system enables simultaneous 3-D measurements of range of motion, speed of movement and torques in the lumbar back in a highly accurate and reproducible manner. The results are used to classify the status of LBP in terms of severity and disability. They enable us to assess quality of performance and to detect the "symptom magnification syndrome" (SMS), patients with non-physiologic complaints and behavior. We describe in detail the measurement protocol and the exact definitions and criteria used in the process of patient classification. Finally we present the results of our first 238 patients tested. A highly significant difference in almost all measured and calculated parameters was found between the patients with physiologic behavior and those with SMS or nonphysiological behavior. Findings related to all classifications are presented.

Traumatic separation of the symphysis pubis during pregnancy: a case report.

OBJECTIVE: To present an unusual case of traumatic extensive separation of the symphysis pubis during pregnancy and rationale for mode of treatment. DESIGN: Diagnosis for etiology of public and lower back pain following trauma in a 37-year-old woman in an advanced stage of pregnancy. METHODS: Physical examination and plain anterioposterior X-rays. CONCLUSION: Extensive traumatic separation of the symphysis pubis might result from a very forceful descent of the fetal head against the pelvic ring upon the mother's accidental falling. Propitious timing of a caesarian section permits the option of open reduction and internal fixation.

Femoral notchplasty in the treatment of malunited intercondylar eminence fractures of the tibia.

A block of full extension may occur after malunion of an intercondylar tibial eminence fracture. Five patients with this complication were treated by arthroscopic femoral notchplasty. At follow-up, between 6 months and 5 years, four patients had regained full extension and the fifth was improved. This is an effective method of regaining extension in selected patients.

Osteoporosis and increased bone fractures in cerebrotendinous xanthomatosis.

Significant osteoporosis determined by skeleton radiography and bone densitometry was found in 15 patients with cerebrotendinous xanthomatosis (CTX) whose mean age was 31 +/- 11 years. In three CTX patients, bone biopsies confirmed osteoporosis. Nine patients also sustained bone fractures following minimal trauma. Serum 25-hydroxyvitamin D ([25-OHD] 14.6 +/- 6.6 ng/mL v [normal] 30.4 +/- 8.0 ng/mL; P < .001) and 24,25-dihydroxyvitamin D ([24,25(OH)2D] 1.2 +/- 0.4 ng/mL v [normal] 2.7 +/- 0.8 ng/mL; P < .001) levels were low. Serum concentrations of 1,25(OH)2D, calcium, inorganic phosphorus, alkaline phosphatase, parathyroid hormone, and calcitonin were normal. Patients showed classic manifestations of CTX, including dementia, pyramidal and cerebellar insufficiency, peripheral neuropathy, cataracts, and tendon xanthomas associated with elevated serum cholestanol concentrations. These results demonstrate that extensive osteoporosis and increased risk of bone fractures are components of this inherited disease.