Biomedical subjects
Publications and source records attributed to D Paley.
Report of an unusual case, that of a 60-year-old man who experienced concomitant bilateral anterior shoulder dislocations with associated bilateral brachial plexus and axillary artery injury. The report also highlights some of the bony and neurovascular lesions associated with shoulder dislocation.
Volar dislocations of the distal radioulnar joint are often missed initially. Late closed reduction of this joint is generally unsuccessful. Even acute reductions of the distal radioulnar joint is often incomplete or unsuccessful. This is not the case for dorsal dislocations. Obstruction to reduction may be due to the contracted volar soft tissues in late cases or to the dynamic pull of the pronator quadratus acutely. A previously unrecognized cause for difficulty in reduction is the torn triangular fibrocartilaginous complex (TFCC). When the tear occurs at its dorsal insertion on the radius, leaving the TFCC attached to the volar radius and to the ulna, it may block the reduction of the ulnar head into the sigmoid notch. Open reduction is required in such cases with repair of the TFCC.
Since bone marrow has been shown to contain osteoprogenitor cells, an experiment was devised to test its effects when injected percutaneously into osteotomies and 2-cm bony defects produced in rabbit radii. The parameters tested included callus volume, breaking load, tensile strength, and cross-sectional area of callus at the fracture or bony defect site. At two weeks postgrafting callus volume was significantly higher (p less than 0.01) in the grafted radii than in the contralateral saline controls. By four weeks all four parameters were significantly greater in the bone marrow grafted radii than in the contralateral saline controls. Serial radiographs and histology confirm this advanced fracture healing in the grafted bones. The earlier and more abundant callus, at the bone marrow grafted sites, was felt to provide earlier and greater stability, resulting in decreased early healing time when contrasted with the saline controls. Similarly, the bony defects that were grafted with bone marrow united by a bony bridge, whereas the saline controls did not. Percutaneous bone marrow grafting is a simple semi-invasive technique that may have potential clinical applications.
Congenital diffuse hemangiomatous involvement of the entire left thigh and knee joint in a 12-year-old girl was complicated by a Kasabach-Merrit type of consumptive coagulopathy. Repeated pathologic fractures of the left femur resulted in a nonunion. She also had a progressively increasing leg-length discrepancy, a stiff contracted knee, and leg atrophy distal to the knee. She was misdiagnosed originally as a Klippel-Trenauney syndrome, the progress of which is usually self-limited progression and involution. Despite steroid treatment, femoral artery banding, and intramedullary fixation of her femur, the hemangioma caused progressive debilitation of her left lower limb. At age nine, nonunion progressed to marked osteolysis and was treated by a through-knee amputation. A review of the literature revealed much confusion about multiple syndromes associated with angiomatous involvement of the lower limb. Prognostically, the depth and extent of the lesion were the most significant characteristics. This is well illustrated in this long-term follow-up study showing diffuse deep involvement that led to eventual amputation. Furthermore, this patient presents a multitude of complications developing from large angiomas.
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Symptoms associated with subclavian artery stenosis are related to reduced cerebral or arm blood flow. A large difference in blood pressure between the two arms is associated with symptoms of arm ischemia alone and is usually caused by an anatomic variant. The presence or absence of a radiologic steal alone did not seem to determine the type or presence of symptoms. The type of cerebral symptoms seems to be determined by the location of other extracranial vascular stenosis. In patients with hemispheric symptoms there was a higher incidence of anterior circulation insufficiency and a greater reduction in the overall cerebral blood flow. In patients with nonhemispheric symptoms a higher incidence of posterior circulation insufficiency occurred. There may be a small group with nonhemispheric symptoms and a subclavian artery stenosis in whom reversed vertebral artery blood flow is the sole determinant. Perhaps more accurate delineation of other extracranial vascular stenosis would help determine what stenosis in addition to the subclavian artery occlusive disease determines the presenting symptoms. Surgical repair of these lesions may lead to an improved cure rate in this group of patients.
Gastric emptying, gastric secretion and esophageal pH were studied prospectively in 32 patients who had either a Lortat-Jacob type operation (n = 7) or a fundoplication with a 360 degrees (n = 4), 270 degrees (n = 5) or 180 degrees (n = 16) gastric fundic wrap. The goal was to determine the effects of various antireflux mechanisms on these functions as well as to try to explain abnormal postoperative esophageal pH scoring indexes. Esophageal pH was recorded during the 3 h period following a standard meal. Acid reflux was expressed using a scoring index taking into account the duration and magnitude of pH fall. Preoperatively, all patients had an abnormal pH scoring index. Postoperatively, the pH scoring index remained increased in 7 patients (group A) and returned to normal values in 25 (group B). Clinical data, esophageal pH parameters and gastric acid secretion measured preoperatively were not significantly different in the two groups of patients. Preoperative gastric emptying for liquids was shorter in group A than in group B patients (p less than 0.05). Postoperative gastric emptying of radiopaque markers was not different in the two groups of patients. Postoperative resting pressure of the lower esophageal sphincter was always less than 10 cm H2O in group A and more than 10 cm H2O in group B patients. Changes in lower esophageal pressure after surgery were higher in group B than in group A patients (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
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Our case demonstrates how metastases may be present and symptomatic long before they produce sufficient osseous changes to render the lesions radiologically detectable. A case of leiomyosarcoma arising in the uterus and initially presenting as a femoral lesion is presented. It required an intensive review of the case history and of the previous pathology in order to identify the primary site in the uterus. In the literature nine cases of metastatic leiomyosarcoma presenting initially in bone are reviewed. Ten additional cases from the literature showed bone metastases as the first site of recurrence. When this is assessed together with some 14 cases of primary leiomyosarcomas reported arising in bone, one is impressed that this is an uncommon tumour in bone either as a primary or secondary. In all patients in whom a leiomyosarcoma is histologically proven in bone, all primary sites should be specifically and categorically excluded before the lesion is accepted as an osseous primary. This should include special stains for myofibrils and electron microscopy if at all possible, in order to differentiate such tumours from other sarcomas such as fibrosarcoma. This applies especially to patients with uterine lesions that have been previously treated, even if they have been regarded as benign initially. All previous pathology and in particular hysterectomy specimens should be carefully reviewed. The need to specifically identify a leiomyosarcoma as a primary lies in the different modalities of treatment used: aggressive ablative surgery for primary lesions as opposed to radiation and chemotherapy for metastatic disease.
Exteriorized renal allografts that protrude abnormally after dehiscence of transplant wounds pose a rare but formidable surgical problem. If good renal allograft function is present and wound sepsis is controlled, the renal allograft need not be removed even if the wound cannot be approximated. The exposed kidney behaves like other body soft tissues, and resurfacing the renal cortex with skin autografts can be performed successfully. We present four cases demonstrating that split-thickness autografts can be successfully utilized to cover an exposed renal allograft with salvage of allograft function. The incidence of this situation was 0.62% in a series of 641 consecutive renal transplants. We also observed, incidentally, that there was no apparent linkage between the HL-A complex and the tendency for keloid formation.
On the basis of a new case of sub-adventitial cystic degeneration of the popliteal artery, the authors review the characteristics of this condition. The diagnosis may be suspected on the basis of clinical and arteriographic findings in an individual in whom the arterial system is otherwise normal. The various aetiological hypotheses are recalled. Treatment in the majority of cases consists of simple excision of the cyst. Intimal changes or segmental obstruction impose the need for resection with restoration of continuity by bypass.
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Coagulase-negative staphylococci (CONS) are occasionally cultured from foci of osteomyelitis in otherwise healthy individuals and are usually regarded as contaminants. The present report describes two children with subacute osteomyelitis of the distal tibia in which pure cultures of CONS were obtained from bone. In one patient, the infection was multifocal, and CONS were isolated from two anatomical sites at two different times. In the other patient, the infection was unifocal, and CONS were cultured from two separate specimens obtained from the same site. In both patients, the symptoms progressed until appropriate antibiotic treatment was initiated. CONS isolated from cultures of bone should not automatically be disregarded. Appropriate antibiotic therapy may result in clinical resolution.
Limb lengthening is still a major procedure with potentially serious complications. It does not, however, deserve the reputation it gained over the last few years. With a proper understanding of the biology, biomechanics, and strategies of lengthening, excellent results can be consistently obtained with relatively few complications.
Unrecognized flexion injuries of the cervical spine may lead to late instability and neurologic damage. These hidden flexion injuries may be from acute or chronic traumatic episodes. Cervical spine instability was seen in an amateur high jumper as a result of chronic repetitive flexion loading of her cervical spine due to incorrect landing technique. The instability from these types of flexion injuries is generally unrecognized on a routine lateral radiograph. The presence of slight anterior subluxation, simple compression fractures, or subtle kyphotic angulation at one cervical level should alert the physician to this diagnosis. Flexion extension views are useful to demonstrate this instability. Occupations and sports which involve repetitive flexion stress to the cervical spine are at risk for this type of late instability. Therefore, in high jumping careful attention to safe techniques of landing is of utmost importance.
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