Pioneering efforts for minority appointments and academic surgery. A narrative.

The author gives a narrative chronologic explanation for the early inclusion of African Americans and other minorities into the Yale University Orthopaedic Surgical Residency Training Program. The author's early isolation from racial problems living in rural Nebraska and the paucity of racial friction at the University of Nebraska gave him a more neutral or positive view of other cultures. Sudden exposure to the racial tension and police brutality toward African Americans in Boston followed by the well defined racial bias in the Southern city of Baltimore showed the plight of minorities. At that same time the author encountered many gentle and extremely intelligent African Americans who performed outstanding medical tasks for the Johns Hopkins Hospital hospital with little educational background. The author's experience with Shirley Moore and Augustus White at Yale made it possible to recruit a diverse group of gifted and loyal resident staff. The high number of academic appointments in minority and majority residents has evolved from the Academic Training and Research Program and a special selection process for choosing residents.

The pathology of acute chondro-osseous injury in the child.

Skeletal tissues from children sustaining acute skeletal trauma were analyzed with detailed radiologic and histologic techniques to assess the failure patterns of the developing skeleton. In the physis- and epiphysis-specific fracture propagation varied, usually going through the portion of the hypertrophic zone adjacent to the metaphysis. However, the physeal fracture in types 1 and 2 sometimes involved the germinal zone. There may also be microscopic propagation at oblique angles from the primary fracture plane, splitting cell columns apart longitudinally. The cartilage canals supplying the germinal zone appear to be "weak" areas into which the fracture may propagate, especially in infancy. Incomplete type 1 physeal fractures, which cannot be detected by routine radiography, may occur. Types 1, 2, and 4 physeal injuries may be comminuted. In type 3 injuries, discrete segments of physis that include the germinal zone may "adhere" to the metaphysis, separating the cells from their normal vascularity. In types 2 and 3, comminution may occur at the site of fracture redirection from the physis. Direct type 5 crushing of the physeal germinal zone does not occur, even in the presence of significant pressure-related changes within other areas of the epiphysis. Type 7 separation between cartilage and bone at any chondro-osseous epiphyseal interface may occur, but is similarly impossible to diagnose radiographically. In the metaphysis torus, fractures result from plastic deformation of the cortex, coupled with a partial microfracturing that may be difficult to visualize with clinical radiography. Some of the energy absorption may also be transmitted to the physis, causing metaphyseal hemorrhage adjacent to the growth plate and variable microscopic damage within the physis. In the diaphysis, the greenstick fracture is associated with longitudinal tensile failure through the developing osteons of the "intact" cortex. The inability of these failure patterns to "narrow" after the fracture force dissipates is the probable cause of retained bowing (plastic deformation). In both torus and greenstick fractures, the fractured bone ends show micro-splitting through the osteoid seams. In the diaphysis, metaphysis, and epiphyseal ossification center there may be areas of focal hemorrhage and microfracture that correlate with the reported MRI phenomenon of "bone bruising." Again, such injury cannot be diagnosed during routine radiography.

A patient registry for orthopedic surgery.

Identification of patient subpopulations for retrospective clinical studies, documentation of residents' clinical experience, and other administrative purposes can be difficult and time consuming. The problem of identification is exacerbated when a teaching program involves several hospitals or when the desired subpopulation is not adequately defined by standard diagnosis or procedure codes used by the institution. A useful patient registry system is reported here for the storage and retrieval of data on orthopedic patients treated by surgical residents at a major teaching hospital and its affiliates. The registry uses a simple, yet powerful encoding scheme to describe patient entries. In addition to a multidimensional encoded description based on SNOMED, the system supports the entry of free text to provide greater detail. This combination gives the patient registry both power and versatility.

Duration of symptoms and disc configuration in chemonucleolysis.

Previous studies have compared the effectiveness of chemonucleolysis with surgery, but currently, no objective criteria have been correlated with the clinical outcome. The authors reviewed 28 cases where the patients had undergone chymopapain injection to determine the significance of disc herniation size, disc space height reduction, and the duration of symptoms on clinical outcome. All patients had a complete history, physical examination, and discogram, and most had pre- and post-injection computerized tomography (CT) or myelogram. Nine of the 28 patients were considered clinical failures. Seven underwent laminectomy and discectomy and were improved markedly. Two patients were advised to have surgery but refused and were considered clinical failures. The causes of failure were unknown in three patients, free fragment in two patients, and diabetic neuropathy in one. Only two patients who did well showed complete resolution of the disc deformity on repeat CT scan. The remainder still had evidence of an avascular deformity that persisted although reduced in size. The failures showed no changes in disc size. The height of the disc space was too variable to be correlated with clinical outcome. Patients who failed had a longer duration of symptoms than the ones who did well (15.1 months for failures vs. 5 months). Therefore, some reduction of disc deformity size, but not necessarily complete reduction, is necessary for a good result, and the enzyme is not as effective in patients with long-standing symptoms.

The anterior retropharyngeal approach to the upper part of the cervical spine.

Since 1959, we have used a superior extension of the anterior approach to the cervical spine of Robinson and Smith in a consecutive series of seventeen patients. This approach provided anterior access to the neural elements from the clivus to the body of the third cervical vertebra, without the need for posterior dissection of the carotid sheath or entrance into the hypopharynx or oral cavity. It also provided adequate exposure for the insertion of iliac or fibular strut grafts, which was necessary in thirteen patients. The approach gave excellent exposure for anterior intralesional excision of a tumor in ten patients, marginal excision of an osteochondroma, two corpectomies of the second cervical vertebra combined with removal of the odontoid process, corpectomy of the second cervical vertebra for the treatment of fixed atlanto-axial subluxation, removal of a bullet anterior to the clivus, reduction of a dislocation of the second on the third cervical vertebra secondary to an unstable fracture of the pedicles of the second cervical vertebra, and anterior débridement for treatment of pyogenic vertebral osteomyelitis. In contrast to the reported results of transmucosal approaches to the atlas and axis, there were no infections or iatrogenic neurological deficits of the spine in the present series. Twelve patients who were followed for two years or more had a solid anterior fusion and no subsequent loss of cervical stability. Pain in the neck was relieved in all of the patients who had had a pathological or traumatic fracture.

Three-dimensional load-displacement curves due to forces on the cervical spine.

Load-displacement curves were measured for six types of pure force loading of the cervical spine specimens obtained from fresh human cadavers. A new measuring and mounting technique was developed that yielded data for all of the functional spinal units for each specimen tested. All five of the coupled, as well as the main, load-displacement curves were studied. For anterior and posterior shear loadings, the main resulting motions were translation in that direction (1.6 +/- 0.3 and 1.9 +/- 0.3 mm), and the major coupled motions were flexion and extension (3.6 degrees +/- 1.2 degrees and 6.3 degrees +/- 1.2 degrees). The main motions with right and left lateral shear loadings were translations laterally (1.4 +/- 0.3 and 1.6 +/- 0.3 mm), and the major coupled motions were axial rotations (1.5 degrees +/- 0.6 degrees and 2.3 degrees +/- 0.6 degrees) and not lateral bending. For compression and distraction loadings, the main motions were translations in that direction (0.7 +/- 0.3 and 1.1 +/- 0.3 mm), and the major coupled motions were flexion and extension (2.0 degrees +/- 1.0 degrees and 2.8 degrees +/- 1.0 degrees) and lateral bending (1.4 degrees +/- 0.3 degrees and 1.9 degrees +/- 0.3 degrees). The neutral zones for anterior and posterior shear forces were 1.6 +/- 0.2 mm of translation and 5.8 degrees +/- 1.3 degrees of rotation, for lateral shear force 1.4 +/- 0.3 mm and 2.0 degrees +/- 0.5 degrees, and for compression/distraction 0.6 +/- 0.1 mm and 2.8 degrees +/- 0.9 degrees.

Radiology of postnatal skeletal development. XIII. C1-C2 interrelationships.

Composites of C1 and C2 were analyzed in various roentgenographic projections to elucidate osseous interrelationships and the effect of overlap of different portions of these two vertebrae in standard radiographic projections during differing stages of postnatal chondro-osseous transformation. In anteroposterior projections the dentocentral synchrondroses of C2 normally was located below the inferior rim of the C1 anterior ossification center. The upper extent of the dens ossification center was behind this anterior C1 center. The overlap made visualization of the ossiculum terminale difficult. The spinous process of C1 could be confused with the ossiculum. In transverse projections, the normal laxity characteristic of young children allowed considerable variation in rotational interrelationships. Various degrees of such instability are illustrated. In lateral views variation of the anterior contour of the dens was significant. Such variation must be considered developmental due to the location and direction of growth of the chondrum terminale and interactive modeling between C1 and C2 to allow extension at this particular joint.

Posterior cervical fusion with rigid internal fixation.

Rigid fixation of the posterior cervical spine offers definite advantages over conventional wiring techniques. These advantages are emphasized in certain high-risk groups of patients, including those with multiple-level traumatic instability, cervical deformities, and unresectable anterior tumor involvement. Early fusion with minimal external fixation is another important advantage. The focus of this article is the concept of rigid internal fixation of the posterior cervical spine and the application of specific techniques used to achieve this goal.

Biomechanical study of cervical spine stabilization with methylmethacrylate.

Polymethylmethacrylate (PMMA) has been used to provide immediate fixation in the spine, especially in the cervical region. With its use spreading to nontumor cases and a younger patient population, its biomechanical contribution to the stability and strength of the injured spine becomes increasingly important. The present study is unique, as it provides, for the first time, results of a three-dimensional stability and flexion strength testing of a surgical specimen removed at autopsy after 7 years. Also tested, in the identical manner, is a normal specimen to provide control data. The PMMA specimen, as compared with the control, was generally found to have less motion. Its flexion strength was at par with that of the control, although it did not exhibit the initial low-stiffness region of the normal spine specimen.

Effect of femoral stem length on stress raisers associated with revision hip arthroplasty.

The objective of this study was to experimentally determine the optimal length of a femoral component in revision total hip arthroplasty (THA). Embalmed cadaveric femurs were loaded in a physiologic manner, and strains on the lateral cortex were measured. Two kinds of defects were tested to simulate THA after removal of a nail plate and after removal of a loose femoral stem. A drill hole was made in the lateral cortex of the femur to simulate the removal of a nail plate. A reaming defect was made, using flexible reamers to thin the cortex from the lesser trochanter distally to a site corresponding to the tip of a standard femoral component, to simulate THA after removal of a previously inserted femoral stem. Femurs were tested intact, with the defects, and after insertion of femoral components with stem lengths of 100 to 250 mm. The strain increased with the creation of a defect and decreased with the insertion of an implant. For a femur with a defect, the strain was minimized when the stem length extended 1.5 femoral diameters past the defect.

Acute prolapsed lumbar intervertebral disc. An epidemiologic study with special reference to driving automobiles and cigarette smoking.

An epidemiologic case-control study to identify risk factors for acute prolapsed lumbar intervertebral disc was undertaken in Connecticut during 1979-1981. This paper focuses on nonoccupational factors of possible etiologic significance. Persons in their 30s were affected most frequently. Among surgical cases, the ratio of men to women was 1.5 to 1, while among probable and possible cases not undergoing surgery, the male to female ratio was about 1 to 1. Cigarette smoking in the past year was associated with an increased risk for prolapsed disc. The greater the number of hours spent in a motor vehicle, the higher the risk. Use of Swedish and Japanese cars was associated with a lower-than-average risk, while use of other cars was associated with a higher-than-average risk. For each type of car, older cars were associated with higher risks than newer cars. Variables that did not affect the risk for prolapsed lumbar disc in this study included height, weight, number of pregnancies, number of children, frequency of wearing shoes with high heels, smoking cigars or pipes, and participation in baseball or softball, golf, bowling, swimming, diving from a board, tennis, bicycling or jogging.

An epidemiological study of acute prolapsed cervical intervertebral disc.

In this epidemiological study of acute prolapsed cervical intervertebral disc, we found that people in the fourth decade of life were affected somewhat more frequently than individuals in other age groups, and men with a prolapsed cervical disc outnumbered women by a ratio of 1.4 to one. Factors that were associated relatively strongly with this diagnosis were frequent lifting of heavy objects on the job that was held around the time of the onset of symptoms, cigarette-smoking, and frequent diving from a board. Positive associations that were of borderline statistical significance or were not statistically significant were found with operating or driving vibrating equipment and time spent in motor vehicles. Variables that did not appear to affect the risk for a prolapsed cervical disc included participation in certain sports other than diving, frequent wearing of shoes with high heels, the number of pregnancies or live births, frequent twisting of the neck on the job, time spent sitting on the job, and smoking cigars or a pipe.

Occult injuries of the talus diagnosed by bone scan and tomography.

Five patients, four women and one man, were found to have an osteochondral lesion of one of the talar joints. All patients had normal plain radiographs of the ankle and foot and were referred to us as a second or third consultation for undiagnosed ankle and hindfoot pain. Bone scans of the tali demonstrated the specific talar joint that was injured, and tomography confirmed the presence of an osteochondral lesion. The average delay in the diagnosis between the onset of symptoms and the initiation of treatment was over 10 months. Bone scanning is an effective diagnostic tool in locating injuries of the talus not appreciated on routine x-ray.

An epidemiologic study of lifting and twisting on the job and risk for acute prolapsed lumbar intervertebral disc.

An epidemiologic case-control study undertaken in Connecticut during 1979-1981 indicated that persons with jobs requiring lifting objects of more than 11.3 kg (25 lb) an average of more than 25 times per day had over three times the risk for acute prolapsed lumbar intervertebral disc as people whose jobs did not involve lifting objects of this weight. If the body was usually twisted while the lifting was done, this elevation in risk was apparent with less frequent lifting. An especially high risk for prolapsed lumbar disc was associated with jobs involving lifting objects of more than 11.3 kg with the body usually twisted and the knees not bent while the lifting was done. Neither lifting objects of less than 11.3 kg nor twisting without lifting was associated with an increase in risk.

Treatment of subtrochanteric fractures with a high-angle compression hip screw.

In a series of 25 subtrochanteric fractures transfixed with high-angle compression hip screws, there were no mechanical failures, delayed unions, or nonunions. Osseous union occurred in a mean time of 3.6 months. Malunion occurred in two instances, at least one of which was the result of technical error at the time of reduction. Rapid mobilization of patients with subtrochanteric fractures is an attainable goal. Early partial weight-bearing should be possible. Although no one internal fixation appliance may be optimal for all fractures in the subtrochanteric region, the high-angle compression hip screw is efficient for the fixation of a wide variety of fracture patterns that otherwise would have been difficult to manage.

Comparison of cyclic loading versus constant compression in the treatment of long-bone fractures in rabbits.

UNLABELLED: The strengths of healing long-bone fractures treated in two different mechanical environments were compared using a rabbit experimental model. Constant compression was applied to one healing tibial fracture, while the other was subjected to cyclic compression. At six weeks of healing, the group of tibial fractures treated with cyclic loading exhibited significantly higher torque and energy absorption to failure and lower stiffness than their pair-mates treated with constant compression. No statistically significant differences were detected at four or eight weeks of healing, although there was a suggestion that compression-treated bones may be stronger in the earlier phases of healing. CLINICAL RELEVANCE: This experiment suggests that the requirements for rapid fracture-healing may vary with the stage of healing; that is, rigid immobilization applied during the initial stages of healing followed by intermittent compression during later stages.

Electrical injury involving the immature skeleton.

Two patients are presented with significant problems of skeletal development and function consequent to electrical impulse propagation through the immature skeleton. Amputation stump revision in the first case allowed an opportunity to assess specific histologic and morphologic changes. Electrical damage completely destroyed portions of trabecular bone in the metaphyses and epiphyseal ossification centers. There were morphologic irregularities in the physis of the distal femur, while in the proximal tibia complete cessation of growth occurred through presumed electrical ablation of the physis. There was virtually no endosteal or periosteal callus, no intertrabecular inflammatory response, and no new bone formation well over a year following the original injury. The knee joint exhibited severe fibrous ankylosis. In the second case localized arrest of the posterolateral portion of the proximal tibial physis caused a valgus/recurvatum deformation, and probably slowed down distal growth sufficiently in the stump end to prevent irregular terminal overgrowth of the tibia, although it did occur in the fibula.

Spinal stabilization in acute spinal injuries.

Stabilization of acute spinal injuries is of prime importance in prevention of further neurologic compromise, prevention of late spinal deformity with associated risk of neurologic compromise, prevention of painful pseudarthrosis, and in maximizing rehabilitation. Many questions regarding the best care and stabilization of the injured spine, particularly those associated with spinal cord injury, remain unanswered. Certainly a diversity of opinion regarding these issues exists between various centers throughout the country today. Hopefully the development of the Regional Spinal Cord Injury Center concept will allow collection of clinical data sufficient to standardize care of these patients in the future.

Correction of spinal instability and recovery of neurologic loss following cervical vertebral body replacement. A case report.

While replacement of cervical vertebral bodies may be required when they are compromised by infection, tumor, or injury, or when they impinge on the neural elements, this procedure does not add immediate stability and may cause additional problems. In this case, displacement of a large fibular graft into the spinal canal appeared to cause additional spinal cord and nerve root injury. Despite a long delay, decompression and firmly fitted and wired anterior and posterior grafts seemed to enhance the neurologic recovery and permitted rapid mobilization. The diagnostic value of computerized tomography is also demonstrated.