Disseminated intravascular coagulopathy (DIC) complicating intramedullary fixation of impending femur fracture from metastatic prostate cancer.
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Adenocarcinoma↗
Biomedical subjects
W G Ward
Publications and source records attributed to W G Ward.
Imaging of the total hip arthroplasty.
More than 75,000 total hip arthroplasties are done yearly in the United States. Although modern cementing techniques have improved the longevity of cemented implants, uncemented prostheses have become popular, especially in younger, more active patients. There is also a trend toward modular components. These mechanical devices will all ultimately fail if subjected to sufficient use and stresses over time, though the specific causes and modes of failure vary widely. Loosening remains the primary cause of implant failure. There is a growing awareness of the role of wear particles in periprosthetic bone resorption with or without loosening. Stress shielding, dislocation, periprosthetic and prosthetic fractures, infection, heterotopic ossification, and stress concentration are also frequently encountered clinical problems. Conventional radiographs are the mainstay in evaluating total hip arthroplasty, with computed tomography and nuclear medicine imaging playing smaller roles.
Follow-Up Studies↗
Total femoral endoprosthetic reconstruction.
Twenty-one consecutive total femoral replacements performed at 2 institutions were reviewed. The surgical indications varied and included bone loss caused by tumor resections (12 patients), failed prior massive partial femoral endoprostheses (6 patients, 5 of whom had prior tumor resections), or difficult to treat fractures and nonunions (3 patients, 2 of whom had prior endoprostheses). Two patients with tumors died within 2 months. The results in the 19 longer-term survivors were satisfactory in 16 patients (good in 7, fair in 9) and poor in 3. Although not commonly used, when this method was indicated it provided an option to hip disarticulation, which often was the only other viable option. Age was the prime determinant of clinical outcome. Average active hip and knee range of motion was better in younger patients (< 60 years old, 66 degrees and 81 degrees, respectively) than in older patients (> or = 60 years old, 43 degrees and 49 degrees, respectively). All household ambulators required walkers and had a mean age of 81 years; community ambulators requiring 1 cane had a mean age of 46 years; and community ambulators using no walking aids had a mean age of 22 years.
Adolescent↗
Imaging of the total knee arthroplasty.
We have reviewed the essentials of TKA imaging. Because the purpose of a knee arthroplasty is to relieve pain and improve function, radiographs should be viewed in the context of these goals.
Humans↗
Pulmonary metastases of stage IIB extremity osteosarcoma and subsequent pulmonary metastases.
PURPOSE: This study investigated prognostic factors in nonmetastatic high-grade extremity osteosarcoma and the prognosis following resection of subsequent pulmonary metastases, with emphasis on the effect of chemotherapy-induced tumor necrosis. PATIENTS AND METHODS: We reviewed 111 consecutive patients with high-grade nonmetastatic extremity osteosarcoma treated with preoperative chemotherapy and surgical resection, with additional review of 36 patients who had subsequent pulmonary metastases resected. RESULTS: The overall 5-year survival rate was 53%. In resected primary tumors, tumor-free resection margin (P < .001) and increasing chemotherapy-induced tumor necrosis (> 90% threshold, P < .003) correlated with increased metastasis-free survival. Relative risk factors for metastases were as follows: tumor-containing resection margin (most likely to metastasize); poor response to preoperative chemotherapy and/or lack of postoperative chemotherapy (next worse prognosis); and excellent response to preoperative chemotherapy (> or = 90% necrosis) combined with postoperative chemotherapy (best prognosis). The 5-year survival rate following pulmonary metastasis resection was 23%, whereas a 0% 4-year survival rate followed development of bony metastases (P < .001). The extent of tumor necrosis in resected pulmonary metastases did not affect prognosis. Survival was best in patients with three or fewer pulmonary nodules (P < .048), four or fewer recurrent pulmonary nodules (P < .047), unilateral pulmonary metastases (P < .037), or longer intervals between primary tumor resection and metastases (P < .082). CONCLUSION: Intensive preoperative and postoperative chemotherapy combined with complete resection of both primary and metastatic pulmonary osteosarcomas is justified, with a goal of 100% tumor necrosis and excision. Although current treatment regimens allow effective salvage therapy for a few patients with pulmonary metastases, more effective systemic treatment is needed.
Adolescent↗
Ganglion cyst of the proximal tibiofibular joint causing anterior compartment syndrome. A case report and anatomical study.
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Adult↗
Shoulder pyarthrosis: a concomitant process.
Thirty cases of glenohumeral pyarthrosis are reported. Systemic immune compromise and local tissue abnormalities were each present in 74% of the adult patients. Both were present in 52%. Most adult patients were debilitated by chronic diseases. Diagnosis was frequently delayed due to mild symptoms and minimal, nonspecific laboratory findings. Poor results correlated with treatment delay. Shoulder pyarthrosis occurred ipsilateral to forearm arteriovenous dialysis fistulas in four patients. Postoperative shoulder pyarthroses were eradicated only in patients with clinically intact immune systems. Three patients (10%) with intact rotator cuffs had unsuspected associated subacromial bursa abscesses. Evaluation of suspected glenohumeral pyarthrosis should include evaluation of the subacromial bursa.
Adolescent↗
Extraskeletal telangiectatic osteosarcoma.
The first three well-documented cases of pure, extraskeletal telangiectatic osteosarcoma of the soft tissues are presented in this article. The distinctive gross features were a predominance of large, blood-filled spaces, which, on histologic examination, were large blood-filled cavities in association with cyst-like walls containing anaplastic spindle cells and definite osteoid production in two of three cases. One of the cases is of additional clinical interest because the teen-aged daughter of the woman patient had died 1 year previously of a high-grade intramedullary osteosarcoma of bone.
Adult↗
Elbow arthroscopy in a mostly athletic population.
The effectiveness of elbow arthroscopy was assessed in 35 consecutive patients (primarily weight lifters and baseball players) treated by one surgeon. The most commonly treated lesions were loose bodies and impinging spurs. Most elbow problems resulted from repetitive or acute athletic trauma. Repetitive stress injuries usually involved the athlete's dominant arm (91%). A standardized rating system demonstrated significant improvement at 24 months' average follow-up. Flexion and extension improved an average of 9 and 6 degrees, respectively. Elbow arthroscopy appears to be a safe and effective treatment for athletes, allowing most a full return to participation in sports.
Activities of Daily Living↗
Extramedullary porous coating to prevent diaphyseal osteolysis and radiolucent lines around proximal tibial replacements. A preliminary report.
Nineteen patients who had a primary malignant bone tumor of the proximal end of the tibia were managed with wide resection and implantation of a tibial endoprosthesis with cement, combined with a rotating-hinge knee replacement. In the first ten patients, a ring of porous coating was applied to the part of the tibial replacement that was just proximal to the intramedullary portion of the stem, to encourage ingrowth of bridging bone. No growth of bone into these porous rings occurred, and the rings were not applied to the next nine endoprostheses. During the subsequent follow-up period, progressive osteolysis (resorption of more than two millimeters of the proximal end of the remaining tibial cortex) developed in only one patient (who had a deep infection) in the group of ten patients who had a porous ring, compared with five of the nine patients who did not have a porous ring but in whom osteolysis developed. This difference was significant (p < 0.001). In addition, the tibial osteolysis was associated with the subsequent development of progressive periprosthetic radiolucent lines at the bone-cement interfaces (p = 0.001). We postulated that, in the patients who had an extramedullary porous ring, the periprosthetic fibrous capsule that formed around the extramedullary portion of all the implants became firmly adherent to the ring, thereby sealing off the part of the capsule that was distal to the ring. The particulate wear debris that was contained within the articular portion of the capsule could not reach the distal tibial bone surrounding the prosthetic stem, and debris-incited osteolysis, which leads to loosening, did not develop. If this mechanism is confirmed, it could have important implications for the design of implants that are used in joint replacement.
Adolescent↗
Subacromial/subdeltoid bursa abscesses. An overlooked diagnosis.
Four subacromial/subdeltoid bursa abscesses were treated in four patients with systemic illnesses. The symptoms and signs of abscesses were minimal in all four patients. In three patients who were chronically ill and debilitated, diagnosis was established only after subacromial space abscesses were encountered during incision and drainage of the glenohumeral or acromioclavicular joint. In these three patients, the subacromial bursa abscesses coexisted with clinically diagnosed mild or resolving shoulder pyarthrosis. All had intact rotator cuffs. The subacromial/subdeltoid space should be evaluated in all cases of suspected glenohumeral pyarthrosis. Computed tomography or magnetic resonance imaging may help detect abscesses and indicate surgical therapy.
Abscess↗
Osteoid osteoma diagnosis and management with low morbidity.
Wide excision, a recommended treatment for osteoid osteoma, creates needless resection of surrounding bone and causes difficult intraoperative nidus identification. Less bone resection is required by successively burring through the reactive bone to identify the nidus, which is then removed with curettes and burrs. This burr-down technique requires precise preoperative anatomic localization by thin section (1-1.5 mm) computed tomography (CT) scans. In a consecutive series of 19 osteoid osteomas, 18 were accurately diagnosed before operation, using a combination of clinical findings, plain roentgenograms, and CT scans. The burr-down technique was successfully used in 15 cases, and four were treated with wide excision. There have been no local recurrences. The follow-up period for all 19 patients was at least six months. No bone grafts were required in the burr-down group in nonspinal locations; there have been no fractures despite early return to unrestricted activity. The burr-down technique was associated with less postoperative immobilization, a shorter duration of protected weight bearing, and an earlier return to activity. The burr-down technique is recommended for accessible osteoid osteoma lesions.
Adolescent↗
Arthroscopic elbow findings: correlation with preoperative radiographic studies.
Correlation between arthroscopic findings and preoperative radiographic studies (plain radiographs and arthrotomograms) was performed in a consecutive series of 37 elbows. Arthrotomograms added significant diagnostic information unavailable from plain radiographs alone, thereby improving the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic efficiency (accuracy) in the evaluation of elbow joint surface changes, marginal spurs, and loose bodies. Arthrotomograms gave 85% accuracy for bone spurs, 89% accuracy for joint surface abnormalities, and 89% accuracy for loose bodies (88% accuracy overall), whereas plain radiographs demonstrated 69% accuracy for bone spurs, 71% accuracy for joint surface abnormalities, and 75% accuracy for loose bodies (72% accuracy overall). The arthrotomograms had 100% sensitivity for loose bodies as well as a 100% negative predictive value for loose bodies. Arthrotomograms are indicated when additional preoperative diagnostic accuracy is necessary. These radiographic studies approached only 90% accuracy, confirming that diagnostic arthroscopy adds additional information.
Arthrography↗
myc protooncogenes of wool and hair growth.
The growth of hard keratin fibers such as wool and hair is dependent on the proliferation of cells in the follicle bulb. If the cells leaving the bulb could be induced to undergo an extra division, then fiber growth should increase. The cellular division within the follicle is complex and probably involves one or more growth factors, which act by altering the expression of transcription factors and other nuclear proteins. We propose that the expression of the myc protooncogenes is a central part of this mechanism. In support of this hypothesis we have detected the mRNAs for TGF-beta 1, basic FGF, TGF-alpha, and c-myc in plucked wool follicles using PCR amplification. We have also shown that the TGF-beta 1, TGF-beta 2, TGF-beta 3, EGF, TGF-alpha, basic FGF, N-myc, and c-myc genes are expressed in mouse skin, and we looked for changes during the hair cycle. The PCR data suggest that in whole skin the levels of mRNA for TGF-beta 1, TGF-beta 2, TGF-alpha, and c-myc do not change. In Quackenbush mice the levels for N-myc, TGF-beta 3, and basic FGF mRNA appear to be lower at the end of the hair cycle. We have confirmed in CBA/C57 black mice that lower levels of N-myc mRNA are detected when hair growth ceases in catagen and telogen. To test our hypothesis further and to assess its practical application, we are making transgenic mice in which the N-myc gene is overexpressed in the hair follicle by way of a wool keratin promoter. The transgene consists of 3.3 kb of 5' sequence from an ovine type 1 IF gene, the murine N-myc genomic coding sequence, and an SV40 polyadenylation signal. The native keratin type 1 IF gene is expressed exclusively in the wool follicle, as shown by in situ hybridization. However, in mice the injection of the transgene has resulted in high embryonic mortality and some embryos with large body size and head malformations. Since these mice were not transgenic, this is likely to be an effect of transient expression of the transgene during embryogenesis. The two transgenic mice produced so far have a normal phenotype.
Aging↗
Occult orthopaedic trauma in the multiply injured patient.
A retrospective review of 111 multitrauma patients revealed that of 401 orthopaedic injuries, 24 injuries (6%) were not initially diagnosed in 20 patients. Patients with occult injuries tended to have greater overall trauma, as reflected by lower trauma and lower Glasgow coma scores and longer hospital and intensive-care unit stays. Twenty prospectively identified cases were added to the series to further define risk factors. Seventy percent of occult bony injuries were ultimately diagnosed by physical examination and plain radiographs alone. Only 27% of cases required sophisticated imaging techniques for diagnosis. Based on these 44 cases of occult injuries in multitrauma victims, the following risk factors were identified: (1) significant multisystem trauma with another more apparent orthopaedic injury within the same extremity, (2) trauma victim too unstable for full initial orthopaedic evaluation, (3) altered sensorium, (4) hastily applied emergency splint obscuring a less apparent injury, (5) poor quality or inadequate initial radiographs, and (6) inadequate significance assigned to minor signs/symptoms in a major trauma victim. Due to the nature and extent of the overall trauma, all injuries cannot be diagnosed on initial patient evaluation.
Adult↗
Endoprosthetic replacement for stage IIB osteosarcoma.
Over an eight-year period, 100 patients with IIB osteosarcoma have been managed. Eighty-one were treated with limb-salvage procedures, 78 of which involved reconstruction utilizing endoprostheses. Only 19 patients received amputation as the primary treatment for local control. Since 1984, all patients received preoperative and post-operative adjuvant chemotherapy. Those patients who received chemotherapy had a statistically significant improvement in five-year survival over those who did not (57% and 32%, respectively, p = 0.014). The functional results were good overall, with excellent results seen in distal femoral reconstruction. Twenty-eight of the 78 patients treated with endoprosthetic reconstruction experienced 30 complications (36%). Mechanical failure was the most common complication (10%) but was generally correctable. The local recurrence rate was 5% and the infection rate was 3%. Local complications were manageable. A statistical analysis revealed that the relative risk of patient death was 2.5 times higher than prosthesis failure for the 78 patients with endoprosthetic reconstruction. The intermediate-term results, with a median follow-up period of 43 months, remains encouraging.
Adolescent↗
Reconstruction of tibial bone defects in tibial nonunion.
The management of tibial nonunions with small and large bony defects is discussed. Factors that prevent union and techniques for eliminating or minimizing these factors are presented.
Bone Transplantation↗
Anterior staple capsulorrhaphy for recurrent dislocation of the shoulder: a clinical and biomechanical study.
Thirty-three anterior staple capsulorrhaphies of the shoulder were reviewed at an average 49.7 months postoperatively (range 12 to 127 months); one postoperative dislocation occurred. The patients' quality of athletic participation improved with surgical therapy in 50%, remained the same in 38%, and was lowered in 12%. Average loss of external rotation was 11.4 degrees with the arm adducted and 13.9 degrees with the arm abducted 90 degrees. A positive apprehension sign persisted in 50%. Shoulder function was good or excellent in 84%. Mild pain was admitted by 55%, moderate pain by 6%, and severe pain by 3%. Staple malpositioning or loosening was identified in 12 shoulders; six of these patients had attributable clinical problems. Biomechanical studies in porcine bone were used to demonstrate that predrilling facilitates proper staple positioning without compromising staple fixation strength and, in a synthetic trabecular model, that a 5 degrees variance in the alignment of the staple holder during staple insertion weakens the fixation strength by 51% (P less than .001). The operation usually prevents recurrent dislocation, permits recovery of normal (or near normal) shoulder motion, and allows satisfactory return to competitive athletics. If staple malpositioning and loosening occur, they may cause clinical problems, including degenerative arthritis. Though most patients (92%) stated they would again have the operation, when practical, we recommend other methods of repair of capsule and labral detachment.
Adult↗