Search

The potential use of 111In-chloride as a radiopharmaceutical for quantitating the extent of synovitis was investigated in a rabbit model of antigen-induced arthritis. Rabbits with monoarticular disease were injected with 111In-chloride and imaged at 30 minutes and 24, 48, 72, and 96 hours. In control knee joints, the ratio of activity in the knee to a soft-tissue region in the thigh remained constant (1.5-1.85:1); in arthritic knees, the 111In uptake ratio increased from 2:1 to 3.2, 3.5, 3.9, and 4.6:1 at the later time points. The difference between the knee-to-soft-tissue ratios observed in the control and involved joints was significant (P less than .01, 48-96 hr). Tissue distribution measurements demonstrated that the synovium and intra-articular structures covered by synovium in arthritic joints had the highest concentration of 111In. In control joints, these tissues were found to take up tenfold less activity. Good correlation was observed between the 111In knee-to-soft-tissue ratios calculated from the images and histologic assessment of the severity of synovitis.

Screws and staples are used frequently in the surgical treatment of glenohumeral joint problems. We analyzed a series of thirty-seven patients with complications related to the use of these implants. Twenty-one patients had problems related to the use of screws for affixing a transferred coracoid process to the glenoid. Sixteen patients had problems related to the use of staples: ten had undergone capsulorrhaphy, four had had advancement of the subscapularis, and two had had repair of a rotator cuff tear. The complaints at examination were shoulder pain (thirty-six patients), decreased glenohumeral motion (nineteen patients), crepitus with glenohumeral motion (sixteen patients), and radiating paresthesias (four patients). The time between placement of the implant and the onset of symptoms ranged from four weeks to ten years. The screws or staples had been incorrectly placed in ten patients, had migrated or loosened in twenty-four, and had fractured in three. Thirty-four patients required a second surgical procedure specifically for removal of the implant. At operation fourteen patients (41 per cent) were noted to have sustained a significant injury to the articular surface of the glenoid or humerus. The results in this group of patients indicated that screws and staples can produce complications that require reoperation and are capable of causing a permanent loss of joint function. Adequate surgical exposure and careful placement of the implant appear to be essential when these devices are used about the glenohumeral joint.

The results of bunion surgery on 50 feet in 31 adolescents are reviewed. Average follow-up was 3 years 2 months. The failure rate was 36%. Fifty-one percent of the children had hypermobile flatfeet, and 32% had a long first ray. The recurrence rate in these groups was 56 and 50%, respectively. There were 20 reoperations for either recurrence (12) or hardware removal (eight). Elective bunion surgery in adolescents should only be performed in the face of progressive, painful deformity where both the patient and the patient's parents fully understand the goals and risks of surgery.

From 1979 to 1982, 64 femoral shaft fractures in 62 patients were treated by closed interlocking nailing at Harborview Medical Center, Seattle, WA, U.S.A., and Parkland Memorial Hospital, Dallas, TX, U.S.A. Twenty-nine patients sustained multiple system injuries and 29 of the involved extremities (45%) had at least one additional injury. There were 17 (26%) open fractures. Static mode nailing was used to treat 52 fractures; dynamic mode nailing was performed for 12 fractures. Patient follow-up averaged 17 months (range 7-41 months). The average time to union was 13.5 weeks. Normal femoral length within 1 cm was achieved in 97% of cases. Knee range of motion averaged 127 degrees. Complications (9%) included two delayed unions, one nonunion, two cases of shortening or lengthening of more than 1 cm, and one case of malunion with angulation or more than 10 degrees. The delayed unions and nonunions healed after one additional procedure. This study shows that closed interlocking nailing is a safe, effective technique that provides stable fixation in most unstable femoral shaft fractures. This technique represents a major advance in the treatment of difficult femoral shaft fractures that would be poorly suited for standard closed nailing.

Dysprosium-165-ferric hydroxide macroaggregates (165Dy-FHMA) was used as an agent of radiation synovectomy in an antigen-induced arthritis model in New Zealand white rabbits. Animals were killed up to 6 months after treatment. 165Dy-FHMA was found to have a potent but temporary antiinflammatory effect on synovium for up to 3 months after treatment. Treated knees also showed significant preservation of articular cartilage architecture and proteoglycan content compared with untreated controls, but only during the first 3 months after treatment. In animals killed 3 and 6 months after treatment there were only minimal differences between the treated and untreated knees, indicating that the antiinflammatory effects on synovial tissue and articular cartilage preservation were not sustained.

One hundred and twenty one knees in 97 patients with seropositive rheumatoid arthritis and persistent knee synovitis were treated with the intra-articular injection of 270 mCi (30 GBq) of dysprosium-165 (165Dy) bound to ferric hydroxide macroaggregates. Of 81 knees evaluated at one year, 61% had good results, 23% had fair results and 16% had poor results. Of 44 knees evaluated at two years, 64% had good results, 16% had fair results and 20% had poor results. Knees with Stage I radiographic changes showed 72 and 81% good results at one and two years, respectively. Knees and Stage II radiographic changes showed 53 and 48% good results at one and two years, respectively. Leakage of radioactivity from the injected joint was minimal. Mean leakage to the venous blood was 0.15% of the injected dose. Mean leakage to the liver 24 h after injection was 0.64% of the injected dose. Mean leakage to the draining inguinal lymph nodes was 0.17% of the injected dose. These results indicate that 165Dy-ferric hydroxide macroaggregate is an effective agent for radiation synovectomy, particularly in knees with Stage I radiographic changes. The minimal leakage rates observed offer a definite advantage over previously used agents.

One hundred eight knees of 93 patients with seropositive rheumatoid arthritis and persistent synovitis of the knee were treated with an intraarticular injection of 270 mCi of dysprosium 165 bound to ferric hydroxide macroaggregate. Leakage of radioactivity from the injected joint was minimal. Mean leakage to the venous blood 3 hours after injection was 0.11% of the injected dose; this corresponds to a mean whole body dose of 0.2 rads. Mean leakage to the liver 24 hours after injection was 0.64% of the injected dose; this corresponds to a mean liver dose of 3.2 rads. In 7 additional patients examined, there was negligible or near negligible activity found in the draining inguinal lymph nodes. One-year followup was possible for 74 knees (63 patients). Sixty-one percent of the knees had good results, 23% had fair results, and 16% had poor results. There was a direct correlation between the radiographic stage and response to treatment. In knees with stage I radiographic changes, 72% showed good results; 93% showed improvement. In knees with stage II changes, 59% showed good results; 81% showed improvement. These preliminary results indicate that dysprosium 165-ferric hydroxide macroaggregate is an effective agent for radiation synovectomy. The low leakage rates observed offer a definite advantage over agents previously used.

Between 1969 and 1981, 20 acetabular augmentations were performed on 17 cerebral palsied patients with progressive hip instability. Average follow-up was 41.5 months, with a range from 24 to 147 months. Evaluation of results was based on assessment of hip stability, center edge (CE) angle, range of motion, and postoperative complications. Eighteen hips were rated good, one fair, and one poor. Stability was achieved in 19 hips. The CE angle was increased from a preoperative mean of -17 degrees to a follow-up mean of 50 degrees. There was no significant difference between preoperative and follow-up hip range of motion. The only complication encountered was a supracondylar femur fracture sustained after spica cast immobilization. Acetabular augmentation can be used effectively in the treatment of progressive hip instability in patients with cerebral palsy.

We describe a patient who had septic arthritis caused by Clostridium perfringens. Clostridial organisms are very uncommon causes of septic arthritis. Only 13 cases have been reported previously. The diagnosis should be suspected in patients with a history of penetrating joint trauma and in immunocompromised patients. Successful treatment has usually consisted of surgical synovectomy in combination with high-dose intravenous penicillin therapy. Multiple aspirations of affected joints as a definitive treatment should be used with caution and only in patients who are not candidates for surgery.

An unusual case of bilateral posterior fracture-dislocation of the hip (Pipkin Type IV) occurred in a 63-year-old man with Paget's disease of the pelvis. Other injuries included a displaced humeral shaft fracture and patellar ligament disruption. Bilateral cemented total hip arthroplasty was performed to avoid the need for prolonged immobilization. Postoperative low-dose irradiation was used because of the risk of heterotopic ossification.

Because of failure to fully respond to an initial intraarticular injection of dysprosium 165-ferric hydroxide macroaggregates, 17 patients with seropositive rheumatoid arthritis underwent repeat radiation synovectomy using this agent. Of the 13 patients who were evaluated 1 year later, 54% (7 knees) had good results, 31% (4 knees) had fair results, and 15% (2 knees) had poor results. The initial lack of significant benefit from radiation synovectomy did not appear to preclude a favorable response to a second injection.

Benign solitary schwannomas of the foot are a rare occurrence; only four cases have been previously reported. A schwannoma associated with the medial plantar nerve present for more than 40 years before the onset of symptoms was diagnosed in a 73-year-old man. Excision of the mass, with preservation of the involved nerve, was possible and successfully relieved symptoms.

The biomechanical characteristics of anatomic reduction versus medial displacement osteotomy were compared for four-part intertrochanteric fractures experimentally produced in cadaver femurs. Eighteen pairs of femurs were assigned randomly to either the anatomic (A) or the medial displacement (MD) group and instrumented with multiple strain gauges. The femurs in the MD group were tested while intact and following four-part fracture with fixation. The femurs in the A group were first tested intact, followed by a stable two-part fracture with fixation, and then by a four-part fracture with fixation and perfect reduction of the posteromedial fragment (PMF) with a lag screw, partial reduction of the PMF, and with the PMF omitted. All fractures were fixed with a 135 degrees, four-hole, sliding hip screw. The strain distribution in the MD group changed significantly after fracture. The plate tensile strain increased by 360% while the compressive calcar strain decreased 85%. The plate tensile strain in the A group also increased significantly after four-part fracture when the PMF was perfectly reduced (160%), partially reduced (290%), or discarded (275%); the calcar compressive strains for these subgroups decreased approximately 50%. This laboratory study indicates that anatomic reduction of four-part intertrochanteric fractures with the sliding hip screw, regardless of the presence or position of the PMF, provides significantly higher compression across the calcar region and significantly lower tensile strain on the plate than fractures reduced by medial displacement osteotomy. The more physiologic strain distribution and the increased medial load transmission support the use of anatomic reduction for the treatment of unstable intertrochanteric fractures.

Proximal humeral fractures are commonly seen in orthopedic practice. The vast majority of these fractures are nondisplaced. Infrequently, displaced proximal humeral fractures have associated neurovascular injuries. Injury to the brachial plexus is uncommon; axillary artery injury is rare. This is a report of two displaced proximal humeral fractures in elderly, intoxicated patients following low-energy trauma. Both fractures resulted in axillary artery injury requiring vascular reconstruction. Only nine similar cases were found in a review of the literature. Displaced proximal humeral fractures should be carefully evaluated for vascular injury, and arteriography should be used when necessary. If vascular reconstruction is indicated, the fracture must be internally fixed to prevent redisplacement and potential compromise of the vascular repair. Serial postoperative Doppler examinations are necessary to detect thrombus formation. With prompt diagnosis and treatment, prolonged limb ischemia and its sequelae can be prevented.