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Study Design. Randomized controlled trial comparing OP-1 (rhBMP-7) with iliac crest autograft in patients with symptomatic degenerative spondylolisthesis and spinal stenosis treated with decompression and uninstrumented posterolateral arthrodesis. Objective. To determine the safety and the clinical and radiographic efficacy of OP-1 (rhBMP-7) Putty as compared with an iliac crest bone autograft control in uninstrumented, single-level posterolateral spinal arthrodesis. Summary of Background Data. Preclinical and preliminary clinical data have demonstrated successful fusion and clinical outcomes with the use of OP-1 Putty in posterolateral spinal arthrodesis. No prior randomized controlled trial with adequate study power has been performed. Methods. A total of 335 patients were randomized in 2:1 fashion to receive either OP-1 Putty or autograft in the setting of an uninstrumented posterolateral arthrodesis performed for degenerative spondylolisthesis and symptomatic spinal stenosis. Patients were observed serially with radiographs, clinical examinations, and appropriate clinical indicators, including ODI, Short-Form 36, and visual analog scale scores. Serum samples were examined at regular intervals to assess the presence of antibodies to OP-1. The primary end point, Overall Success, was analyzed at 24 months. The study was extended to include additional imaging data and long-term clinical follow-up at 36+ months. At the 36+ month time point, CT scans were obtained in addition to plain radiographs to evaluate the presence and location of new bone formation. Modified Overall Success, including improvements in ODI, absence of retreatment, neurologic success, absence of device-related serious adverse events, angulation and translation success, and new bone formation by CT scan (at 36+ months), was then calculated using the 24-month primary clinical endpoints, updated retreatment data, and CT imaging and radiographic end points. Results. OP-1 Putty was demonstrated to be statistically equivalent to autograft with respect to the primary end point of modified overall success. The use of OP-1 Putty when compared to autograft was associated with statistically lower intraoperative blood loss and shorter operative times. Although patients in the OP-1 Putty group demonstrated an early propensity for formation of anti-OP-1 antibodies, this resolved completely in all patients with no clinical sequelae. Conclusion. OP-1 Putty is a safe and effective alternative to autograft in the setting of uninstrumented posterolateral spinal arthrodesis performed for degenerative spondylolisthesis and symptomatic spinal stenosis.

Magnetic resonance (MR) arthrography has been demonstrated to be more accurate than MR imaging alone in the identification of a variety of musculoskeletal pathology. While the complication rate of intra-articular gadolinium: saline injection has been shown to be relatively low, MR arthrography is more invasive, painful, and costly, and less convenient, than MR imaging alone. The purpose of this study was to evaluate patients' perception of the fear and discomfort, and to assess their overall acceptance of the intra-articular gadolinium injection.Between October 1997 and January 1998, 113 outpatients who were referred to Yale-New Haven Hospital for MR arthrography of the ankle, elbow, hip, knee, shoulder, or wrist were asked to complete a questionnaire rating their fear of factors most commonly associated with the procedure including "pain", "needles", "complications", and "discovery of results that would lead to surgery". In addition, after having undergone the intra-articular gadolinium:saline injection, patients were asked to rate their perception of pain.While many patients expressed fear of "pain" and "needles", after having undergone the injection their overall pain rating score was low. Only 6% actually found gadolinium arthrography more painful than expected.Despite the fact that patients expressed apprehension about certain aspects of MR arthrography, subjects who underwent the intra-articular gadolinium injection considered the discomfort less than expected. Clinicians should not hesitate to order MR arthrography because the accuracy of the procedure is high enough that patients accept the discomfort.

Seven uninjured and three injured patients were studied using midsagittal computed tomographic (CT) images at 10° increments from full extension to full flexion. Each injured patient had a confirmed scapholunate ligament tear and normal radiographs. CT bony contours were digitized, and incremental motion determined using a specifically designed automated contour-matching algorithm. We expressed wrist motion as a ratio of lunocapitate (midcarpal) motion, and radiolunate (radiocarpal) motion. In normal wrists, motion occurred equally at the midcarpal and radiocarpal joints. In wrists with scapholunate ligament disruption, lunocapitate motion increased significantly throughout the arc of motion.

We describe a 23-year-old woman with neuritis ossificans involving the tibial, common peroneal and lateral sural nerves. She presented with chronic debilitating posterior knee pain. An MRI scan showed masses in these nerves, biopsy of which revealed a histological diagnosis of neuritis ossificans. Treatment with OxyContin and Neurotin for two years resulted in resolution of symptoms. Follow-up MRI demonstrated a resolution of two of the three masses. There was a persistent area of ossification without associated oedema in the common peroneal nerve. Neuritis ossificans has the histological appearance of myositis ossificans and follows a similar clinical course. The success of conservative treatment in this case suggests that the potential complications of surgical excision can be avoided.

A case of multiple glomus tumors of the finger is presented, in which MRI was valuable in the diagnosis and preoperative tumor localization.

We present a case of an acute hyper-extension wrist injury that progressed from normal carpal alignment to dorsal intercalated segment instability over a short period of time. Disruption of the scapholunate interosseous and radioscapholunate ligaments was proven arthroscopically, while the intercapsular ligaments were demonstrated to be intact. We have shown that lunate malalignment can occur over time, as secondary lunate ligamentous supports attenuate under abnormal carpal kinetics.

Atlas injuries were produced in vitro and evaluated by radiographic examinations and anatomic studies from a clinical viewpoint. Ten cadaveric human upper cervical spine specimens were subjected to a high-speed axial impact. Injuries to the atlas consisted of six bursting fractures, two ruptures of the transverse ligament, one four-part fracture without a prominent bursting, and one posterior arch fracture. The major soft tissue injury involved the transverse ligament. There were five bony avulsions and three midsubstance tears. In this study, computed tomographic examinations clearly demonstrated the sites of fracture and bony avulsions of the transverse ligament. The best diagnostic tool for function of the transverse ligament was determined to be the atlantodental interval on flexion radiographs. Axial traction force reduced a bursting fracture of the atlas ring. The in vitro atlas injury model gives useful information for clinical diagnosis and treatment.

Understanding injury mechanisms is important for the prevention, diagnosis, and treatment of spinal injuries. Using 10 fresh cadaveric human spine specimens of occiput to C3, clinically similar injuries of the atlas (C1) were produced with high-speed (4.4 m/sec) axial compression. The traumatic event was biomechanically monitored. The resulting injuries were studied with radiography, computed tomography, and a multidirectional instability test. The average compressive failure force was 3,050 N for specimens impacted in neutral posture (n = 437) and 2,100 N for those in extended posture (n = 282). Corresponding values for the impulse were 34.9 Nsec (n = 8.3) and 17.6 Nsec (n = 1.8). Average instability for both groups, as measured by the neutral zone and range of motion, increased by 90% and 44%, respectively, in flexion-extension and 20% in lateral bending, but not in axial rotation. These findings confirm the clinical observations.

A case of a 23-year-old man with deformities of the spine and hip is presented, demonstrating the bizarre long term effects of radiation on developing bone. The spectrum of radiation-induced growth abnormalities is reviewed. Multiple variables, including age of the patient, the quantity of radiation delivered, and the site of delivery, all effect the eventual radiographic appearance.

The use of the resectoscope has several advantages in treating the patient with inoperable obstructive carcinoma of the rectum, particularly when compared with fulguration. It is immediate in its results, as often testified to by the sudden outpouring of blockaded feces. It is also safer in allowing greater amounts of tissue to be resected with less depth of tissue injury by the electrical output. It does, however, require the skills of someone able to handle the instrument, and the procedure should be a joint effort by the surgeon and urologist. The use of the urologic resectoscope should prove to be a useful addition in the surgeon's armamentarium in a selected number of patients.