Late Reconstruction of Neglected Metacarpal Shaft Defects Due to Gunshot Wound

We evaluated eight patients after delayed treatment of nine metacarpal bone defects due to gunshot injuries. The mean length of the metacarpal defects was 3 cm and the average time between the gunshot injury and the reconstruction surgery was 10 months. Although all of the patients had been treated with wound irrigation and debridement immediately following injury, no attempt had been made to repair the metacarpal defect or to maintain metacarpal length. As a result, serious shortening had occurred. After the original length of the metacarpal had been restored by distraction of the soft tissues (1 mm/day), a tri-cortical iliac bone graft was inserted into the bone defect. The average follow-up time was 15 months. Clinical and radiological union was established in all cases after an average of 12 weeks. The mean grip strength of the hand and the mean range of motion of the metacarpophalangeal joint increased by 24% and 60%, respectively.

Treatment of Fractures of the Humeral Capitellum Using Herbert Screws

Isolated fractures of the capitellum are rare injuries and account for 1% of all elbow injuries. The purpose of this study is to evaluate the clinical outcomes of 11 Type I capitellum fractures treated by open reduction and internal fixation using at least two standard Herbert screws between 1998 and 2003. The average age of the patients was 27.5 years. The mean follow-up time was 23.4 months. The final postoperative assessment was made at the 12th month. The results were evaluated according to the Mayo Elbow Performance Index. We obtained excellent result in eight patients and good result in three patients. We recommend open reduction and fixation with Herbert screws inserted from the posterior surface of the lateral epicondyle and early mobilization in Type I fractures of the capitellum.

Tension Band Wiring of Unstable Transverse Fractures of the Proximal and Middle Phalanges of the Hand

Twenty-three isolated, unstable and closed transverse middle and proximal phalangeal shaft fractures in 23 patients were treated by tension band wiring. The tension band was applied with two transverse Kirschner wires that did not cross the fracture line. All of the fractures united and achieved satisfactory functional outcomes. No patient required either physiotherapy or tenolysis or capsulotomy surgery.

Reconstruction of the transverse and dorsal-oblique amputations of the distal thumb with volar cross-finger flap using the index finger

We performed a retrospective review of 12 patients with dorsal oblique and transverse amputations of the distal thumb who were treated with a volar cross-finger flap from the index finger. The mean patient follow-up period was 28 months postoperatively (range: 19-43 months). There were no instances of flap loss, infection, or donor site complication in our series. The mean Semmes-Weinstein monofilament testing scores on the injured thumb and the donor site were 0.65 g (range: 0.16-2 g) and 0.51 g (range: 0.16-1 g), respectively. The mean 2-point discrimination testing scores on the injured thumb and the donor site were 4.5 mm (range: 3-8 mm) and 4.3 mm (range: 3-7 mm), respectively. This study suggests that the volar cross-finger flap using the index finger is a reliable technique in repairing dorsal oblique and transverse amputations of the distal thumb.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand

PURPOSE

To determine the efficacy of pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand.

METHODS

We performed a retrospective study from 1994 to 2013 to evaluate 33 patients in whom pins and rubber band traction was employed. We clinically evaluated the active range of motion of the affected fingers after surgery. Eleven of the 33 fractures were at the proximal interphalangeal joint, 10 at the distal interphalangeal joint, 5 at the thumb interphalangeal joint, and 2 at the metacarpophalangeal joint of the thumb. The remaining 5 patients had complex fracture-dislocation of the proximal interphalangeal joints.

RESULTS

The mean follow-up period was 24 months. The average active motion of the metacarpophalangeal joints of the fingers was 91° (range, extension 0°-10°/flexion 85°-90°), proximal interphalangeal joints was 92° (range, extension/flexion 0°-10°/85°-100°), and distal interphalangeal joints was 73° (range, extension/flexion 0°-10°/60°-80°). The overall average of all active motion of the injured fingers except thumbs was 255° (range, 240°-270°). The average active motion of the of the thumb metacarpophalangeal joint was 56° (range, extension 5°-10°/flexion 50°-55°), and interphalangeal joint was 74° (range, extension 0°-10°/flexion 75°-80°). The average of active motion of the injured thumb metacarpal and interphalangeal joints combined was 130° (range, 125°-135°).

CONCLUSIONS

Pins and rubber band traction is a treatment option for comminuted displaced intra-articular fractures of the digits that offers satisfactory clinical results.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Prospective study of percutaneous radiofrequency nerve ablation for chronic plantar fasciitis

BACKGROUND

Chronic plantar heel pain is one of the most painful foot conditions and is generally associated with plantar fasciitis. This study reports 2-year follow-up results of radiofrequency nerve ablation (RFNA) of the calcaneal branches of the inferior calcaneal nerve in patients with chronic heel pain associated with plantar fasciitis.

METHODS

After receiving approval from the institutional review board, we prospectively evaluated the results of the RFNA of the calcaneal branches of the inferior calcaneal nerve on 35 feet in 29 patients with plantar heel pain between 2008 and 2011. All of the patients who were treated had been complaining of heel pain for more than 6 months and had failed conservative treatment. All of the patients were evaluated (quantitatively) using the average 10-point Visual Analog Scale (VAS) before treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure. We also evaluated 26 feet in 20 patients with American Orthopaedic Foot and Ankle Society scale (AOFAS) scores before the treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure.

RESULTS

The average VAS score of the feet was 9.2 ± 1.9 before treatment, 0.5 ± 1.3 at 1 month after the procedure, 1.5 ± 2.1 at 1-year follow-up, and 1.3 ± 1.8 at 2-year follow-up (P < .001). The average AOFAS scores of the patients were 66.9 ± 8.1 (range, 44-80) before treatment, 95.2 ± 6.1 (range, 77-100) at 1 month after the procedure, 93 ± 7.5 (range, 71-100) at the 1-year follow-up, and 93.3 ± 7.9 (range, 69-100) at the 2-year follow-up. At the 1- and 2-year follow-up, 85.7% of the patients rated their treatment as very successful or successful.

CONCLUSION

These findings suggest that RFNA of the calcaneal branches of the inferior calcaneal nerve was an effective pain treatment option for chronic heel pain associated with plantar fasciitis that did not respond to other conservative treatment options.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

[Treatment of femoral shaft fractures with expandable intramedullary nail]

BACKGROUND

Femoral shaft fractures are usually seen in the young population as a result of high energy traumas and are often accompanied by major organ injuries. In this paper, we aimed to assess the clinical results of expandable femoral intramedullary nails in the treatment of 20 femoral shaft fractures.

METHODS

The average age was 34.7. One fracture was the result of a gunshot wound, type 3A open fracture, and the other 19 fractures were closed. Under fluoroscopic control, all patients underwent elective closed reduction and internal fixation with intramedullary expandable femoral nails (Fixion, Disc-O-Tech; Israel). In case of failed or unacceptable closed reduction, open reduction was achieved with a second incision over the fracture site. Average operation time was 26.3 minutes.

RESULTS

Full union was achieved in all patients. The shortest union time was 12 weeks and the longest 24 weeks, with an average of 15.2 weeks. Results in 15 patients (75%) were excellent, in 4 patients (20%) good and in 1 patient (5%) moderate according to Thorensen criteria.

CONCLUSION

Use of expandable nails provides union without major complications and offers advantages such as less exposure to radiation as seen in distal locking of classical intramedullary nails. In conclusion, the good results of this study show that the expandable femoral intramedullary nail provides a successful option to classical intramedullary nails.

Factitious subcutaneous emphysema of an extremity

The presence of air in the subcutaneous tissue of an extremity constitutes a fearful finding because of the potential devastating consequences for both the extremity and life of the patient. The authors present herein a rare case of self-induced subcutaneous emphysema of the thigh in a young patient, which resulted in aggressive management consisting of IV antibiotics, hyperbaric oxygen therapy, and surgical debridement. Correlation of the various findings of the history, physical examination, imaging and laboratory findings is critical in order to avoid unnecessary radical treatment. In the absence of an apparent cause, factitious disorder should always be considered.

Acute arthroscopic removal of a bullet from the shoulder

Arthroscopic procedures are frequently used for extraction of foreign bodies such as bullets from joints. Retained bullets have some effects as loose bodies that cause mechanical symptoms and destroy articular cartilage. Bullets and lead particles in synovial fluid dissolve in time and cause periarticular fibrosis, chondrolysis, hypertrophic arthropathy, and sometimes chronic lead intoxication. A 21-year-old man was treated after he sustained a gunshot wound to his left shoulder. Shoulder arthroscopy was performed through the standard posterior portal. The bullet was observed in the posterior recess and was removed by means of a 10-mm cannula placed anteriorly. The use of arthroscopy for removal of the bullet from the shoulder joint of this patient minimized surgical dissection and blood loss and reduced the likelihood of complications. The patient was free of symptoms within 1 month. Given the disadvantages of traditional techniques such as heavy blood loss, large incisions, high risk for neurovascular anatomic structures, poor visualization of articular surfaces, and prolonged recovery times, we recommend arthroscopic removal of foreign bodies from the shoulder joint as an excellent choice for the treatment of patients with such intra-articular injuries.

Comparison of outcomes of two different surgeries in regarding to complications for chronic anterior shoulder instability

INTRODUCTION

The purpose of this study is to compare the early clinical results of two techniques in regarding to complications in the patients who suffered from chronic anterior traumatic isolated shoulder instability.

METHOD

Eighty-five patients underwent reconstructive procedures due to chronic isolated traumatic shoulder instability in our clinic between 1990 and 2002. Sixty-four patients in whom preoperatively Bankart lesion were detected with MRI and who participated in the regular follow-up were included in the study. Thirty-four patients were treated with Bankart repair (Group I) and 30 patients were treated with Modified Bristow procedure (Group II). Mean follow-up period was 25 (24-39) months for group I and 28 (24-96) months for group II. All cases were evaluated preoperatively and postoperatively according to Rowe scoring system.

RESULTS

Mean Rowe scores were 90 and 88.1 for group I and II, respectively. Due to recurrent dislocation, four revision surgeries (one in group I, three in group II) were performed. Surgical complications were encountered in group II, just as fracture at the bone block in four cases, nonunion in five cases and removal of loose screw in one case.

DISCUSSION

According to clinical outcomes, both the techniques are useful and feasible for the treatment of the chronic traumatic isolated anterior shoulder instability; however, complication rate is higher in the Modified Bristow technique and, Bankart repair is directed to the anatomic repair of the original pathology.

Management of the bilateral congential dislocation of the hip and knee: a case report

Congenital dislocation of the knee (CDK) is a rare disease and may be associated with other congenital and musculoskeletal disorders. We report our result in the treatment of a patient with CDK and DDH that treated with serial casting and Pavlik harness. Early diagnosis of the CDK is very important non operative treatment usually provides more stabile, greater range of motion and much more quadriceps strength than the surgical treatment. Early reduction of dislocation prevents formation of the knee contracture.

Treatment of rupture of the Achilles tendon with fibrin sealant

BACKGROUND

The optimal management strategy for acute Achilles tendon ruptures is controversial. These injuries historically were treated by nonoperative methods (cast immobilization, bandaging); however, operative repair of the ruptured tendon has become popular.

METHODS

Thirty-two patients who had rupture of the Achilles tendon were treated operatively with use of fibrin sealant, and clinical and functional performance measures were assessed after a mean followup of at least 6 months between November, 1998, and July, 2003. All of the patients were male. Average age was 38.18 (30 to 45) years. All of the patients were followed for at least 18 months after surgery. Average followup time was 22.4 (18 to 56) months. We evaluated all patients according to the scoring system of Thermann et al.

RESULTS

Our results were excellent in 24 patients and good in eight patients. One patient had rerupture 3 weeks after surgery.

CONCLUSION

Fibrin sealants are biologically compatible, hemostatic agents derived from human plasma that can be used instead of suture or suture support. We think that the treatment of rupture of the Achilles tendon with fibrin sealant is a useful treatment, and there is less risk of complications, such as deep infection, than in other operative procedures. We had no wound closure problems, the incision size was small, and the operating time was short. However, it must be remembered that the risk of disease transfer by fibrin sealant application is still present.

Four-point bending strength of transverse osteotomies stabilized with various Kirschner wire and tension wire band configurations

Four different fixation configurations of K-wires of two different diameters were used to stabilize a transverse osteotomy in chicken humerus bones. Four-point bending was applied to these to assess their apex dorsal bending rigidity. The configurations of K-wires included intramedullary, crossed and two with different tension wire band designs. One of these consisted of two transverse K-wires which did not cross the fracture line, around which the tension wire band was placed. The results showed that there was no statistical significance between the two different tension band wiring techniques and that both were superior to the intramedullary and crossed K-wire fixation techniques.

[Early results of reconstruction of chronic anterior cruciate ligament ruptures using four-strand hamstring tendon autografts]

OBJECTIVES

We evaluated the short-term results of reconstruction of anterior cruciate ligament (ACL) ruptures using a four-strand hamstring autograft and cross pin femoral fixation.

METHODS

The study included 62 male patients (mean age 24 years; range 21 to 44 years) with chronic ACL ruptures. Involvement was in the right knee in 32 patients, and in the left knee in 30 patients. All the patients were treated with a four-strand hamstring autograft, cross pin femoral fixation (Transfix, Arthrex and Sling Shot, Mitek), and an interference screw on the tibial side. Forty-one patients received treatment for other meniscal pathologies. Final evaluations were made at the end of postoperative 18 months using the Lysholm and IKDC (International Knee Documentation Committee) scoring systems, Telos stress testing, Tegner activity rating, and radiographs.

RESULTS

The Lysholm scores were good (n=23) or excellent (n=38) in 61 patients, and poor in one patient, the mean Lysholm score being 93.5. The IKDC scores were grade A (n=35) or B (n=26) in 61 patients, and grade D in one patient. Telos stress testing showed a significant difference between preoperative (mean 14.5 mm) and postoperative (mean 2.6 mm) laxity measurements (p<0.001). None of the patients had a graft rupture. One patient who developed grade III instability after postoperative six months underwent second-look arthroscopy followed by revision surgery.

CONCLUSION

Reconstruction of the ACL using four-strand hamstring tendons and cross pin femoral fixation results in considerably high success rates in selected patients.

Biodegradable implants in the treatment of scaphoid nonunions

We reviewed 12 male patients with scaphoid nonunions treated by open reduction, bone grafting, and internal fixation with biodegradable implants made of self-reinforced poly- l-lactic acid. Mean patient age was 22.5 (20-25) years. Ten patients had type D2 scaphoid nonunions with a fracture line in the middle one third, one patient had type D2 nonunion with a fracture line in the proximal one third, and one patient had type D1 distal one-third fibrous union. The mean wrist score (modified Mayo wrist score) was 20.8 (10-40) preoperatively and improved after 22-80 months (55-90). All nonunions healed, and the mean solid union time was 4.5 (3.5-7) months. We obtained excellent results in five patients, good results in four, fair results in two, and a poor result in one. The results of this study offer a valid alternative in the fixation of scaphoid nonunions. The major advantage of biodegradable materials is to eliminate the requirement for the removal of the fixation material.

Proximal oblique crescentic osteotomy in hallux valgus

Twenty-six patients with moderate-to-severe hallux valgus deformities were evaluated before and after treatment. All of the patients had incongruent great toe joints. The patients underwent modified proximal crescentic osteotomy, which was termed proximal oblique crescentic osteotomy. The results were evaluated at an average follow-up time of 55 weeks. Objective criteria were hallux valgus angle, intermetatarsal angle, shortening of the first metatarsal, and angulation at the osteotomy site. Clinical evaluation was made according to the rating system of the American Orthopaedic Foot and Ankle Society. The mean correction of the hallux valgus and intermetatarsal angles was 22.1 degrees and 9.9 degrees, respectively. Short-term results indicate that proximal oblique crescentic osteotomy is effective in the treatment of hallux valgus; its advantages over other procedures include its technical ease and low rate of complications.

Humeral shaft fractures secondary to throwing

Twenty-seven male military recruits with humeral shaft fractures that occurred during throwing of a hand grenade were analyzed to determine the causes and contributing factors of this fracture in recreational pitchers. Average patient age was 22 years (range: 19-27 years). Objective criteria included type and fracture site on radiographs. Subjective data such as throwing style, previous pitching experience, and prodromal arm pain were obtained. The recruits' throwing style was deemed faulty. Analysis of the fracture configurations indicated an external rotation mechanism.

[Treatment of femoral shaft fractures by interlocking intramedullary nailing in adults]

OBJECTIVES

We evaluated the radiological, clinical, and functional results of femoral shaft fractures treated by interlocking intramedullary nailing.

METHODS

Interlocking intramedullary nailing was performed in 48 femoral shaft fractures of 46 patients (35 men, 11 women; mean age 30.5 years; range 20 to 69 years). Of the fractures, 31 were in the right femur, 13 were in the left femur, and two were bilateral. There were 44 closed and four open femoral fractures. The results were evaluated according to the Thoresen criteria. Final evaluations included 44 fractures whose follow-ups (mean 26.9 weeks; range 20 to 56 weeks) were completed.

RESULTS

The mean time to union was 16.5 weeks (range 12 to 42 weeks). Four patients (9%) had a varus angulation, and one patient (2.3%) a valgus angulation of 5 degrees; one patient had a posterior angulation of 10 degrees, one patient had an internal rotation of 10 degrees, and one patient had both an external rotation and valgus angulation of 10 degrees. Two patients (4.5%) developed a shortening of 2 cm. Knee flexion was 90 degrees and extension loss was 15 degrees in one patient. Knee flexion was 90 degrees in two patients, and 110 degrees in one patient. Chronic osteomyelitis developed in one patient who had a segmental femoral shaft fracture. According to the Thoresen criteria, 88.6% of patients had excellent or good results.

CONCLUSION

The high success rate obtained with interlocking intramedullary nailing makes it an appropriate method in the treatment of femoral shaft fractures in adults.

[Ligament reconstruction for the chronic instability of the traumatic thumb carpometacarpal joint]

OBJECTIVES

We evaluated the results of ligament reconstruction performed for chronic instability of the traumatic thumb carpometacarpal joint.

METHODS

Seven male patients with traumatic instability of the thumb carpometacarpal joint underwent ligament reconstruction with the use of the technique described by Eaton and Littler. The mean duration between the traumatic event and the operation was eight months. According to the radiological criteria by Eaton and Littler, five patients had stage I, and two patients had stage II disease. The mean follow-up period was 23 months. The results were assessed according to the criteria by Lane and Eaton.

RESULTS

Postoperatively, the patients' grip strength and pinch strength increased by a mean of 40.4% (range 31% to 50%) and 75.4% (range 62% to 100%), respectively. No increases in the extent of arthrosis were observed in the carpometacarpal joint during the follow-up period. None of the patients developed morbidity associated with the functions of the flexor carpi radialis and the wrist. The results were excellent in four, and good in three patients. No complications occurred such as infection or recurrent instability, nor were there any problems related to the skin and Kirschner wires.

CONCLUSION

Ligament reconstruction for the carpometacarpal joint of the thumb relieves pain and restores stability while preserving a functional range of motion in patients with chronic instability.

Late-term reconstruction of lateral ankle ligaments using a split peroneus brevis tendon graft (Colville's technique) in patients with chronic lateral instability of the ankle

We reviewed 14 patients with chronic lateral instability of the ankle treated by Colville's technique between 1996 and 2001. The mean patient age was 25 (20-35) years and all were men. The mean period between injury and surgery was 25 (18-32) months, and the mean follow-up was 20 (14-32) months. Twelve of the results were excellent and two were good according to the criteria of Chrisman and Snook. All patients returned to normal daily activity levels at an average of 6 months following surgery.

[Short-term results of external fixation of unstable distal radial fractures]

OBJECTIVES

We assessed the effectiveness of external fixation in the treatment of unstable distal radial fractures.

METHODS

Twenty-five patients (19 males, 6 females; mean age 39 years; range 20 to 71 years) with unstable distal radius fractures were treated by external fixation. Three patients had open fractures. According to the AO classification, the fractures were B1 (1 fracture), B2 (2), C1 (8), C2 (10), and C3 (4). External fixator was combined with K-wires or volar plates in 17 fractures. The fixator was used for a mean of 6.6 weeks, and the mean follow-up was 13.5 months. The earliest radiologic-anatomic and functional evaluations were based on the findings obtained at the end of six months. A modified Sarmiento scoring system was used for radiologic-anatomic assessment. For functional assessment, the scoring system proposed by Sarmiento et al. was used, which was based on the Gartland and Werley's system.

RESULTS

Radiologic measurements indicated that anatomical results were excellent in 16 patients (64%), good in eight patients (32%), and fair in one patient (4%). Functional results were excellent in four patients (16%), good in seven patients (28%), fair in 11 patients (44%), and poor in three patients (12%). The complications encountered were pin tract infections in four patients, breakage of the fixator pin holder in one patient, and the development of reflex sympathetic dystrophy in five patients.

CONCLUSION

Our data suggest that high success rates in anatomic results do not closely reflect satisfactory functional results. The protocol to be implemented after the application of the external fixator has to be determined according to the type of the fracture.

[Interlocking intramedullary nailing of humeral shaft fractures in adults]

OBJECTIVES

We evaluated the effectiveness of interlocking intramedullary nailing in the treatment of humeral shaft fractures.

METHODS

Forty-three patients (30 men, 13 women; mean age 42 years; range 20 to 83 years) were treated with interlocking intramedullary nailing for humeral shaft fractures. All fractures but one (type II open) were closed. Three patients had radial nerve, one patient had radial and ulnar nerve dysfunction. As all the nerve lesions were assessed as neuropraxia, no immediate surgical exploration was performed. Intramedullary nailing was performed by closed (18 fractures) and open technique (25 fractures), with (n=22) or without (n=21) reaming. Functional evaluation was made according to the Constant-Murley's shoulder scoring system. The mean follow-up was 16.5 months (range 5 to 40 months).

RESULTS

Radiologically, union was achieved in all patients in a mean of 15.6 weeks. No surgery-associated nerve injuries or infections were encountered. Preoperative nerve dysfunction resolved in all patients in a mean of 12.5 weeks. No signs of rotator cuff impingement or restriction were detected in two patients in whom the nails were placed high in close proximity to the shoulder girdle. Of these, one patient underwent reoperation for the removal of the nail after the fracture union completed. Functional results were excellent in all patients at the end of postoperative three months. No significant correlation was found between the techniques employed and time to union and functional outcome.

CONCLUSION

Interlocking intramedullary nailing provides adequate fixation and early mobilization, and results in satisfactory radiographic and functional results in the treatment of humeral shaft fractures.

[Evaluation of biomechanical rigidity of K-wire configurations in transverse osteotomies: a comparison of four-point bending test results]

OBJECTIVES

Four-point bending test was performed in transverse osteotomies of chicken humerus in order to assess biomechanical rigidity of fixation techniques that are commonly used in transverse unstable fractures of the tubular bones of the hand.

METHODS

Thirty chicken humeral bones were transversely osteotomized and then randomly assigned to six fixation groups equal in number. Osteotomized bones were fixed with the use of two crossed (2 groups) or intramedullary (2 groups) K-wires; in the remaining two groups, crossed K-wires were used in combination with tension band wiring. The sizes of the crossed and intramedullary K-wires were 0.035-inch and 0.045-inch in paired groups, respectively. Biomechanical rigidity was measured by four-point bending test on an Instron testing machine.

RESULTS

The most rigid configuration was obtained with 0.045-inch K-wires, followed by 0.035-inch K-wires used in combination with tension band wiring. These techniques provided significantly increased rigid fixations than those obtained by non-supplemented crossed and intramedullary K-wire fixations.

CONCLUSION

In the transverse fractures of the tubular bones of the hand, dorsally applied tension band wiring around two crossed K-wires provides adequate rigidity that allows early active motion in the postoperative period.

Primary bipolar hemiprosthesis for unstable intertrochanteric fractures

Between 1997 and 2001 we treated 54 elderly patients with unstable intertrochanteric fractures by primary hemiarthroplasty using a cemented bipolar prosthesis. Mean patient age was 75.6 (64-91) years and mean follow-up was 22.3 (5-48) months. Seven patients died before the fourth post-operative month. Thirty-three patients were able to walk with a walker in the first post-operative week. There were no dislocations or aseptic loosening. One deep infection was encountered after 1 year. Acetabular erosion was seen in one patient and non-union of the greater trochanter was seen in four. Five patients experienced leg-length discrepancy. We obtained 17 excellent and 14 good results after 12 months according to the Harris hip-scoring system. We observed that the inner motion of the bipolar head decreased over time.

Effects of stem design and pre-cooling prostheses on the heat generated by bone cement in an in vitro model

The necrotizing effects of the heat, particularly at more than 50 degrees C, produced by the exothermic polymerization process associated with the acrylic implant cement polymethylmethacrylate (PMMA) are well documented. The temperature changes that occur are dependent on the thickness of the PMMA. The current study investigates the hypothesis that the heat produced by the bone cement may be reduced by the choice of stem design and by pre-cooling the hip prosthesis. The thermal alterations at the bone-cement interface were measured in an in vitro model. The results indicated that a temperature decrease of approximately 7 degrees C could be achieved by pre-cooling the prosthesis, and by changing the shape of the prosthesis stem from flat and wide to round.

The effect of passive smoking on the development of respiratory syncytial virus bronchiolitis

In spite of the increasing evidence that passive smoking increases the incidence of respiratory infections and bronchial hyper-responsiveness, the information about whether exposure to sudden heavy smoke enhances the development of acute respiratory infections in children remains inadequate. In this study, to quantitate the level of exposure to environmental tobacco smoke, in 28 children (age ranging 2-18 months) with respiratory syncytial virus (RSV) bronchiolitis and in 30 children (age ranging between 2-15 months) with non-respiratory symptoms, the serum levels of cotinine, the major metabolite of nicotine, were measured at admission to the emergency department. Parents were asked to fill in a questionnaire about the housing conditions and their smoking habits. Serum samples were taken again from the children with RSV bronchiolitis at their second visit at 1 month after discharge from the hospital. The children with RSV bronchiolitis had higher levels of serum cotinine (mean of 10.8 ng/ml) in the acute stage, compared with post-bronchiolitis stage (mean of 7.4 ng/ml). Moreover, patients admitted with non-respiratory symptoms had significantly lower levels of serum cotinine (mean of 3.9 ng/ ml) than both phases of patients with RSV bronchiolitis. Children with RSV bronchiolitis were found to have higher levels of cotinine when either the mother or both of the parents smoked, than the children with non-smoker parents. In conclusion, children admitted to the hospital with RSV bronchiolitis were shown to be acutely exposed to more cigarette smoke after 1 month and much more than the children admitted for non-respiratory diseases. These findings may imply that sudden heavy cigarette smoke exposure may predispose to an acute respiratory infection.

Report of eight cases of humeral fracture following the throwing of hand grenades

A series of eight cases is presented in which similar fractures of the shaft of the humerus occurred during the throwing of hand grenades. Transient paresis of the radial nerve accompanied the fracture in one patient. In seven patients, the fracture healed without complication. In the remaining case, non-union developed, and surgical treatment was instituted. The mechanism of the fracture is discussed with reference to the literature.

Microvascular transplantation of physeal allografts

We compared growth in vascularised allograft transplants, autografts and in non-operated physes in rabbits immunosuppressed with cyclosporin A and in non-immunosuppressed animals. Molecular haplotyping was undertaken before operation to ensure allogenicity. Postoperative bone scans and fluorochrome labelling were used to confirm physeal vascularity. The animals were killed at three or five weeks. Proximal tibial physeal autografts, with or without cyclosporin A, or allografts with cyclosporin A, grew at similar rates to the physes of non-operated rabbits. All the operated physes grew at rates significantly greater than their contralateral controls. 99mTc-MDP bone scans accurately predicted the viability of the epiphyseal plate. Quantitative histomorphological analysis of the heights of the physeal proliferative and hypertrophic zones showed that successful physeal transplants have a normal appearance, but when unsuccessful have thickened hypertrophic zones compatible with physeal ischaemia. We discuss the significance of these results in relation to the transplantation of physes in children.

Microvascular transplantation of physeal allografts

We compared growth in vascularised allograft transplants, autografts and in non-operated physes in rabbits immunosuppressed with cyclosporin A and in non-immunosuppressed animals. Molecular haplotyping was undertaken before operation to ensure allogenicity. Postoperative bone scans and fluorochrome labelling were used to confirm physeal vascularity. The animals were killed at three or five weeks. Proximal tibial physeal autografts, with or without cyclosporin A, or allografts with cyclosporin A, grew at similar rates to the physes of non-operated rabbits. All the operated physes grew at rates significantly greater than their contralateral controls. 99mTc-MDP bone scans accurately predicted the viability of the epiphyseal plate. Quantitative histomorphological analysis of the heights of the physeal proliferative and hypertrophic zones showed that successful physeal transplants have a normal appearance, but when unsuccessful have thickened hypertrophic zones compatible with physeal ischaemia. We discuss the significance of these results in relation to the transplantation of physes in children.

Can quantitative 99mTc-MDP bone scans be used to predict longitudinal growth of epiphyseal plate allografts after microvascular transplantation? An experimental study

Allograft and autograft microvascular proximal tibial epiphyseal plate transplants were performed in female New Zealand White (NZW) rabbits to quantify the growth rate and total growth potential of immunosuppressed and nonimmunosuppressed rabbits. The purpose of this experiment is to examine whether the 99mTc-MDP radionuclide uptake of the transplanted epiphyseal plate at 1 week postoperatively, done to assess anastomotic patency of the transplant, could also serve as a predictor of eventual longitudinal growth of the transplant or replant. All transplants and replants demonstrating positive 99mTc-MDP uptake in the proximal tibial epiphyseal plate at 1 week showed continued longitudinal growth. The precise amount of 99mTc-MDP uptake, however, did not correlate with the amount of growth at 3 and 5 weeks follow-up.