Biomedical subjects
Publications and source records attributed to Y Floman.
The rapid development of an intraosseous ganglion following an intraarticular fracture of the distal radius in a patient suffering from familial Mediterranean fever is presented. The case supports the view that trauma may be an etiological factor in the genesis of intraosseous ganglia.
Trauma to the back from the force of chronic stress is thought to be an etiologic factor in isthmic spondylolisthesis (SLL). The relationship of first degree spondylolisthesis to low back pain (LBP) is controversial. We compare the prevalence of SLL in helicopter pilots who are subject to strong vibrational forces, with other airforce personnel. Helicopter pilots had more than a four times higher prevalence of SLL (4.5%) than did cadets (1.0%) and transport pilots (0.9%). Low back pain was more frequent in pilots with SLL than in those without this lesion but in no case was the pain disabling or the defect progressive. We conclude that SLL may be induced by vibrational forces and although SLL is associated with LBP, the pain was little clinical significance.
Hypobaric spinal anesthesia was administered to 40 patients undergoing lower limb surgery. Twenty-nine of the patients were debilitated geriatric patients who presented with orthopedic emergencies, in most cases a fractured hip. Hypobaric spinal anesthesia was found to be a simple and safe procedure that provided adequate analgesia. Due to its inherent nature, hypobaric spinal anesthesia does not necessitate positioning of the patient on the injured, painful side (unlike hyperbaric spinal or epidural anesthesia) and, therefore, facilitates a smooth and painless transfer of the patient to the operating table. Complications encountered were similar to those following hyperbaric anesthesia.
Marfan's syndrome is a hereditary disorder of connective tissue, involving the ophthalmic, cardiovascular and musculoskeletal systems. Two cases are described in which protrusio acetabuli was a major problem. Otto pelvis should be considered as one of the musculoskeletal manifestations of Marfan's syndrome.
Osseous involvement is usually not appreciated in de Quervain's stenosing tenosynovitis. A case of stenosing tenosynovitis accompanied by significant local osteoporosis in the radial styloid area and a corresponding positive area on a technetium-99m polyphosphonate bone scan provoked the authors' interest in this entity. In seven consecutive patients with de Quervain's disease, six had evidence of osseous involvement of the radial styloid as demonstrated by roentgenographic studies and/or technetium bone scanning. In the process of differential diagnosis of a lytic lesion in the radial styloid area, de Quervain's tenosynovitis should be included.
Platelet functions were investigated in 16 patients with idiopathic scoliosis (IS), in seven patients with congenital scoliosis (CS), and in 12 healthy individuals who served as a control group. All were females, aged 11 to 22 years. Platelet aggregation anomalies were observed in all IS patients. These constituted an impaired platelet-release reaction when aggregation was induced with ADP or epinephrine, but not with collagen or arachidonic acid. A decreased thromboxane A2 synthesis and impaired 14C-serotonin release were also observed when platelets were stimulated with ADP or epinephrine. Platelet from CS patients and the controls did not show any functional abnormalities when stimulated with the above four aggregating agents. The platelet function anomaly in IS patients was not associated with prolongation of the bleeding time, spontaneous occurrence of hemorrhagic episodes, or increased bleeding during invasive procedures, including major spinal surgery. The above findings and the recently described platelet structural anomalies in IS may imply that the pathological process operative in idiopathic scoliosis involves not only the axial skeleton, but also cellular blood elements. The similarity between blood platelets and muscle cells, and the anomalies that have been found in both systems in IS, support the notion that a muscle disorder may be involved in the pathogenesis of the disease.
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Continuous retroperitoneal bleeding may be an immediate life-threatening complication of pelvic fractures. While surgical control of the bleeding vessels has been advocated in these cases, today angiographic embolization of the branches of the internal iliac arteries is proving to be the treatment of choice. This is a relatively simple, safe, prompt and effective method of controlling the hemorrhage. It avoids the disadvantages of surgery, general anesthesia, loss of the tamponade effect of the retroperitoneum when opened, and the not uncommon difficulty of identifying and ligating the bleeding vessels. Two cases in which massive retroperitoneal bleeding associated with pelvic fractures was controlled by angiographic embolization are described, illustrating the importance of early angiography.
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Seventy-three patients with complex spinal deformities undergoing combined staged anterior and posterior fusion were analyzed. The indications for the combined approach were (1) severe kyphosis with or without neural compromise; (2) major thoracolumbar or lumbar curves with trunk imbalance or marked pelvic obliquity; (3) severe congenital scoliotic curves associated with hemivertebrae or anterior unsegmented bars; (4) absent posterior elements, e.g., myelodysplasia, post laminectomy; and (5) failed anterior fusion. In 35 patients with kyphosis, the deformity was reduced on the average from 78 degrees to 48 degrees. In 20 patients with marked trunk decompensation and/or pelvic obliquity due to a major thoracolumbar or lumbar curve, the scoliotic deformity was reduced from an average 85 degrees to 33 degrees. In 18 scoliotic patients with marked vertebral body deformation (hemivertebrae, anterior bars, lateral subluxation), the scoliotic curves were reduced from an average 60 degrees to 46 degrees. Postoperative morbidity was not significantly increased because of the combined procedure. The overall complication rate was high (32/73 patients). In view of this high rate of postoperative morbidity, the combined approach should not be undertaken by the occasional spinal surgeon. In selected far advanced or complex spinal deformities, combined anterior and posterior fusion may be indicated to attain optimal correction of the deformity as well as a solid pain-free fusion.
The value of an osteotomy of the fusion mass in attaining realignment of the spine when a lateral shift of the trunk over the pelvis has developed in the frontal plane was studied in fifty-five patients. All had had a previously fused but progressive spinal deformity. The indications for osteotomy were progression of the curve, imbalance of the trunk, pain, deteriorating cardiopulmonary function, or pseudarthrosis, or a combination of these conditions. Twenty-one patients had idiopathic scoliosis; fourteen, congenital scoliosis; ten, paralytic scoliosis; four, myelodysplastic scoliosis; and six had scoliosis secondary to miscellaneous conditions. A total of 154 osteotomies of the fusion mass, or 2.8 osteotomies per patient, were performed. Nine patients underwent an anterior spinal osteotomy or wedge resection as well. Most had a two-stage procedure which consisted of a posterior osteotomy, halo-femoral traction, and a posterior re-fusion with Harrington instrumentation two weeks later. At an average follow-up of thirty-two months, it was found that osteotomy of the fusion mass enabled the surgeon to realign the trunk over the pelvis and to correct pelvis obliquity, but correction of the angular deformity was only secondary. Although the rate of complications was high (51 per cent, including one postoperative death), osteotomy of the fusion mass and re-fusion may be indicated in a patient with a previously fused but progressively unbalanced, painful deformity of the spine.
Ankylosing hyperostosis of the spine is a distinct clinical entity that merits diagnosis and recognition of its structural limitations. The case of multiple thoracic spine fractures presented here emphasizes the potentially increased susceptibility of involved spines to trauma and also suggests the need to caution diagnosed patients from placing their spines at undue risk.
Acute cholecystitis following the surgical treatment of spinal deformities in the adult is reported in three cases. Although acute cholecystitis is not a rare postoperative complication, it is relatively unknown to orthopedic surgeons and has been seldom reported in the orthopedic literature. A review of the literature dealing with the pathogenesis and clinical manifestations reveals that postoperative cholecystitis is a life-endangering complication which should be promptly recognized. The occurrence of upper quadrant abdominal pain, accompanied by fever, tachycardia and signs of peritoneal irritation after any major orthopedic procedure, should alert the surgeon to the possibility of postoperative cholecystitis. Considering the high incidence of gangrene and perforation of the gallbladder, cholecystectomy is the treatment of choice.
The techniques of fibular bypass grafting for massive tibial bone loss have been well described over the past 50 years. These techniques have generally been used as salvage procedures in post-traumatic civilian patients with chronic sepsis, or for congenital pseudoarthrosis. We present the experience of the Orthopaedic Department of the Hadassah University Hospital in successfully treating massive tibial bone loss by early fibular bypass grafting in four war injuries, where such definitive procedures would have been avoided in the past.