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Nontraumatic clostridial infections are rare, but need to be diagnosed and treated early or high morbidity and mortality rates result. We believe that this is the first reported case of metastatic nontraumatic Clostridium septicum osteomyelitis. Early treatment with surgical debridement and parenteral antibiotics without hyperbaric oxygen was used. An associated occult rectal malignancy was discovered and treated.
Y-shaped vein grafts that have been specifically selected from the venous anatomy on the dorsum of the foot have been used to bridge the arterial defects in multiple digit replantations. In this technique, the two outflow limbs of the Y-shaped vein graft are anastomosed to the distal digital arteries of two adjacent fingers before osteosynthesis. The inflow stem of the Y-shaped graft is then anastomosed to a common digital artery or to the superficial palmar arch to provide rapid and reliable restoration of arterial inflow simultaneously into two adjacent digits.
Foreign body giant cell synovitis and focal bony destruction requiring secondary surgery developed in nine patients after carpal and radiocarpal arthroplasty with silicone rubber implants. Synovitis followed silicone rubber replacement of the lunate in four patients, the carpal scaphoid in two patients, and the trapezium in one patient, trapezial resurfacing hemiarthroplasty in one patient, and total wrist arthroplasty in one patient. All the removed implants were deformed. Some had changed in color from clear white at the time of insertion to yellow-white or deep yellow upon removal. Scanning electron microscopy of a silicone rubber implant of the lunate removed from one patient revealed extensive fibrillation in the capitate fossa. Light microscopy of the synovium revealed hyperplasia and hundreds of fragments of silicone particulate debris throughout the tissue adjacent to the implant. The silicone debris was surrounded by multinuclear foreign body giant cells in the eight patients from whom the synovium was studied. All patients required revision surgery. We believe that in the patients studied, synovitis represented a biologic reaction to the silicone fragments found scattered throughout the synovium for the following reasons: The synovitis found was not present before surgery (except in the patient with rheumatoid arthritis); the synovitis found was not associated with the condition for which replacement arthroplasty was performed (except in the patient with rheumatoid arthritis); synovitis subsided after implants were removed; and synovitis was noted histologically in areas of silicone debris and appeared directly related to silicone seeding. Fibrillation, fragmentation, and local seeding of silicone after carpal or radiocarpal arthroplasty appear related to gradual deformation of the implant, which was the result of repeated compressive loading and shearing. Clinically significant complications of rubber carpal or radiocarpal arthroplasty with silicone rubber implants may develop from silicone synovitis.
Multiple fractures involving the dominant proximal forearm and wrist in a 24-year-old woman were treated with a combination of internal and external fixation. The rigid skeletal fixation permitted rapid postoperative mobilization and a successful functional outcome.
An experimental model using the immature canine proximal fibular epiphysis was developed to isolate and investigate the effects of the epiphyseal and metaphyseal circulations on longitudinal growth. Experimental constructs studied the epiphyseal circulation, the epiphyseal and metaphyseal circulations, a devascularized growth plate, and a control group. Twenty-four limbs were studied by serial x-ray films and microangiographic and histologic analyses at time of death, 24 weeks after surgery. The data from this preliminary study show that both metaphyseal and epiphyseal circulations are necessary for predictable longitudinal growth.
An extensor pollicis longus tendon, ruptured after treatment of a giant cell tumor of the distal radius by packing the cavity with polymethylmethacrylate cement. The lack of extension was treated successfully with tendon transfer of the extensor indicis proprius to the extensor pollicis longus. Pathophysiology of the rupture is discussed.
The use of an interpositional vein graft to restore inflow to the digits by recreating the superficial palmar arch is presented. This technique is best reserved for severe, devascularizing injuries to the hand, significant damage to the palmar vessels, and when they may a paucity of donor vein available.
Three cases of intraarticular osteotomy of malunited intraarticular fractures of the metacarpal head are described. The patients, all young males, had significant improvement in the articular anatomy and function. Rigid internal fixation was used in each case.
In order to understand the effect of malunion on functional outcome, it is essential that deformity be measured in a consistent manner. A standardized method of measuring eight anatomic parameters at the distal radius was developed. By this method, six x-ray films of healed distal radius fractures were subsequently measured by 16 raters. Rater agreement was quantified by using the intraclass correlation coefficient. Tolerance limits were developed in order to estimate the expected margin of error for each parameter. Parameters measured with high rater agreement include ulnar variance, palmar tilt, and radial shift; however, even experienced clinicians did not readily agree on the size of step and gap deformity. Using the method of tolerance limits, one would expect that two randomly chosen clinicians measuring step and gap deformity on a random x-ray film will differ by more than 3 mm at least 10% of the time. Similarly, repeat step or gap measurements by the same observer are expected to differ by more than 2 mm at least 10% of the time. In view of our inability to measure deformity more accurately, the concept of a specific relationship between a given degree of deformity and outcome must be questioned. Prospective research is needed in order to improve our understanding of the precise relationship between malunion and functional outcome.
A new plate designed specifically to address complex wrist pathology was used for the internal fixation of 22 complex fractures of the distal radius in 22 patients in a prospective multicenter trial. The majority of fractures were group C2- and C3-type fractures according to the Comprehensive Classification of Fractures. No plate failures, loss of reduction, nonunions, or infections occurred. Within the average follow-up time of 14 months, the functional results (including an average motion of 76% and an average grip strength of 56% of the contralateral side) were comparable to those reported for similar fractures in previous investigations. Five patients had irritation of the tendons in the second dorsal compartment. This trial serves both as a verification of the safety and efficacy of this distal radius plate as well as a demonstration of its utility in the treatment of complex fractures of the distal radius.
As suggested by Muller, a useful classification system for distal radius fractures must consider the severity of the bone lesion and serve as a basis for treatment and for evaluation of outcome. Although these fractures have long been considered to be Colles or Smith's fractures, they have been subjected to extensive scrutiny in order to define fracture morphology and treatment considerations. This review highlights a number of contemporary classification systems for distal radius fractures, including the systems of Older et al., the Comprehensive Classification of fractures, the Melone intra-articular classification system, and that of Fernandez.
Recognition of the pattern of an elbow fracture-dislocation allows immediate knowledge of the treatment principles, pitfalls, and prognosis of the injury. Specific techniques for each injury component increase the surgeon's ability to restore stability to the elbow. When complications are anticipated and avoided or addressed expediently, it is possible to restore elbow function in spite of the complexity of these injuries.
Six patients with a nonunion of the humeral diaphysis after intramedullary nailing were treated with a wave plate and autologous bone graft but without removal of the intramedullary implant. The mean duration of the nonunion was 19 months (range, 6-36 months). At a mean follow-up of 12 months (range, 6-18 months), all six nonunions had healed, and patient satisfaction was high. Five patients had regained full shoulder function. One patient, who was treated for a rotator cuff tear before the humeral fracture, had a satisfactory functional outcome. Elbow motion was full in all but one patient. One patient had a postoperative radial nerve palsy, which recovered partially but did not require further surgery. This report suggests that healing of humeral nonunions can be achieved in the presence of intramedullary hardware.
A nonunion of a diaphyseal fracture of the humerus can present a major functional problem even in the elderly population. Advances in operative exposures combined with newer techniques of achieving stable internal fixation even in the presence of pathologic bone have enabled the surgeon to successfully treat even the most complex nonunions.
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The clavicle fracture that has united with deformity or shortening may have an adverse effect on normal shoulder girdle function. We report on 4 patients in whom a malunited fracture of the clavicle was believed to be a contributing factor to shoulder girdle dysfunction. In each patient, the functional status of the involved limb was improved after corrective osteotomy at the site of deformity, realignment, and plate fixation.
Two cohort populations consisting of 13 patients with an un-united fracture of the distal radius in whom the distal fragment had more than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion and ten patients with an un-united fracture of the distal radius with a smaller distal fragment were compared. There were no preoperative differences with respect to age, gender, interval between injury and index procedure, preoperative amount of radius tilt, ulnar inclination and ulnar variance, or the preoperative function. Independent of the size of the distal fragment in all patients the distal radius was restored to gain bony union and realignment with preservation of some wrist motion. The length of the follow-up period averaged 30 months for the small fragment group compared with 22 months for the large fragment group. Bony union was achieved in 22 patients. One patient out of the large fragment group failed to heal the fracture and had wrist fusion. At the follow-up examination there were no significant differences in the radiological and clinical outcome between the two groups. No differences were seen on total range of motion of forearm supination and pronation with an average of 135 degrees in the large fragment group and 145 degrees in the small fragment group. Wrist motion revealed no significant differences in the flexion-extension arc, averaging 90 degrees in the large fragment group and 83 degrees in the small fragment group. Total range of motion of radial and ulnar deviation of the wrist was similar, averaging 39 degrees in the large fragment group and 43 degrees in the small fragment group. Grip strength averaged 59% compared with the opposite limb for the large fragment group and 67% for the small fragment group. We believe that the results of reconstruction of un-united fractures of the distal end of the radius for patients in whom the distal fragment had less than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion are comparable to the results for patients with a larger distal fragment. Therefore, we believe that surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.
Infrared (IR) studies of laboratory ices can provide information on the evolution of cosmic-type ices as a function of different simulated space environments involving thermal, ultraviolet (UV), or ion processing. Laboratory radiation experiments can lead to the formation of complex organic molecules. However, because of our lack of knowledge about UV photon and ion fluxes, and exposure lifetimes, it is not certain how well our simulations represent space conditions. Appropriate laboratory experiments are also limited by the absence of knowledge about the composition, density, and temperature of ices in different regions of space. Our current understanding of expected doses due to UV photons and cosmic rays is summarized here, along with an inventory of condensed-phase molecules identified on outer solar system surfaces, comets and interstellar grains. Far-IR spectra of thermally cycled H2O are discussed since these results reflect the dramatic difference between the amorphous and crystalline phases of H2O ice, the most dominant condensed-phase molecule in cosmic ices. A comparison of mid-IR spectra of products in proton-irradiated and UV-photolyzed ices shows that few differences are observed for these two forms of processing for the simple binary mixtures studied to date. IR identification of radiation products and experiments to determine production rates of new molecules in ices during processing are discussed. A new technique for measuring intrinsic IR band strengths of several unstable molecules is presented. An example of our laboratory results applied to Europa observations is included.