Studies on the components in NTU shale oil. VIII. Identification of acyclic isoprenoid hydrocarbons (author''s transl)

A compensating osteotomy for correction of the varus and retroversion components of severe slipped capital femoral epiphysis is presented. It is safer than a cuneiform osteotomy done through the callus of the slipped epiphysis because the line of osteotomy is distal to the major blood supply of the posterior retinaculum. The threaded Steinmann pins used for fixation sross both the osteotomy site and the epiphyseal plate, and therefore not only are the mechanical relationships restored, but further slipping is prevented also.     

Radiographic course after acetabuloplasty and femoral osteotomy in hip dysplasia

The radiographic course of 101 hips with residual dysplasia treated with roof plasty combined with intertrochanteric varus derotation osteotomy using the osteotomy wedge as a roof graft after Mittelmeier were reviewed. The average followup period was 8.8 years. The acetabular angle was improved by an average of 16 degrees (postoperative mean, 19 degrees; average at followup, 18 degrees). The center edge angle also was improved by 16 degrees and was stable at 25 degrees average at followup. The neck shaft angle, abnormal in 70% of hips preoperatively, was reduced by the varus osteotomies to a mean of 111 degrees and showed a spontaneous postoperative increase to normal values of an average of 129 degrees. There was no correlation of the postoperative of the neck shaft angle to patient age, preoperative valgus extension, correction angle, or length of followup. In nearly all cases, an almost anatomic joint shape was achieved. With a complication rate of only 1%, especially regarding the rate of necroses of the femoral head, the presented surgical technique can be recommended as highly effective, reliable, and safe for the treatment of congenital hip dislocation.     

Subtrochanteric femoral shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hip

A surgical technique, which uses a transverse osteotomy, for subtrochanteric femoral shortening and derotation in total hip arthroplasty for high-riding developmental dislocation of the hip is described. Anteversion is set by rotating the osteotomy fragments, and torsional stability is augmented with allograft struts and cables when indicated. Eight patients with 9 total hip arthroplasties were followed for an average of 43 months (range, 24-84 months). Good to excellent results were obtained in 87% of patients (7 of 8). Eight of 9 osteotomies (89%) demonstrated radiographic evidence of healing at an average of 5 months. One patient had an asymptomatic nonunion of the osteotomy site but still had a good overall clinical result. Another patient suffered fatigue failure of a distally ingrown porous device, which necessitated revision total hip arthroplasty 18 months after surgery. Subtrochanteric osteotomy in total hip arthroplasty for developmental dislocation of the hip allows for acetabular exposure and diaphyseal shortening while facilitating femoral derotation. Furthermore, proximal femoral bone stock is maintained and some of the potential complications of greater trochanteric osteotomy may be avoided.     

The intertrochanteric osteotomy in the treatment of congenital dysplasia of the hip

The dysplastic acetabulum develops to normal shape only if the head of the femur is in central position in the articualr cavity correct according to biomechanics of the hip joint. Anterior rotation of the neck of the femur should be reduced operatively to neutral position as soon as possible if joint congruity cannot be achieved by conservative treatment. The indication for an intertrochanteric derotation osteotomy is made in cases demonstrating a roof inclination less than 30 degrees in children age 1 1/2 to three. After the third year of age, the mutual growth-stimulating effect of the articular bodies is not important enough to be useful in treatment of dysplasia. The femoral osteotomy has to be performed intertrochanterically. If articular congruity cannot be achieved by intertrochanteric osteotomy only, an additional innominate osteotomy of the pelvis is indicated at the same stage. The results of 435 cases demonstrated a good development of the acetabular roof if the intervention was performed early, according to correctly specified indications. In cases with insufficient growth potential of the acetabular roof, resulting in an increased inclination, an additional reconstruction of the acetabular cavity is required.     

Evaluation of treatment of hip subluxation in myelomeningocele by intertrochanteric varus derotation femoral osteotomy

A retrospective study of 27 subluxed hips was carried out in 18 patients with myelomeningocele treated by varus derotation intertrochanteric osteotomy. Twenty-three of the 27 hips were stable at follow-up review. The causes of failure were related to the presence of pelvic obliquity secondary to scoliosis or to a dysplastic acetabulum (acetabular index above 25 to 30 degrees). Transfer of the iliopsoas tendon was not found to be necessary in order to achieve stable reduction.     

External rotational positioning of the leg after intertrochanteric combined varus-derotational osteotomy in Perthes' disease

A 13-year-old boy underwent an intertrochanteric combined varus derotational osteotomy (VDO) for Perthes' disease of his right hip. After surgery he walked with his right leg externally rotated. Computed tomography scans of both knees and hips were obtained with the legs in their spontaneous position to evaluate rotation and anteversion. The femoral condyles were in 28 degrees of external rotation on the operated side compared with 2 degrees on the non-operated side. The angle between the femoral neck and the horizontal plane was 32 degrees on both sides. We conclude that there may be a risk that a derotational osteotomy may produce an external rotational position of the leg instead of altering the angle between the femoral neck and the horizontal plane.     

Closed intramedullary femoral osteotomy. Shortening and derotation procedures

Closed osteotomy and nailing were performed on 37 patients for leg-length inequality or rotational deformities. Shortening operations were performed in 31 patients, derotation in six. Preoperatively, the leg-length discrepancy ranged from 2 to 6.6 cm. All femoral shortenings resulted in correction to less than 1 cm. Preoperatively, rotational deformities averaged 58 degrees; all were corrected to within 5 degrees of normal. Follow-up observation averaged 3.3 years. There were no nonunions or infections. All patients regained preoperative joint range of motion (ROM). Thirteen patients were Cybex tested one year or more postoperatively; all had quadriceps and hamstring strength equal to or greater than the contralateral leg, except for two patients who had suffered additional trauma to the shortened femur. Closed femoral osteotomy is an effective, safe, and reproducible means to obtain lower limb length correction in patients with leg-length inequality or rotational abnormality.     

Developing and implementing interprofessional learning in a Faculty of Health Professions

Although medial displacement calcaneal osteotomy has been advocated for treatment of acquired pes planus, no studies have determined the biomechanical consequences at the ankle of such a procedure. The present investigation examined the alteration in ankle motion that resulted from a medial sliding calcaneal osteotomy. In dorsiflexion, the ankle specimens were found to have altered internal rotation and varus alignment. At maximal dorsiflexion, there was a 76% increase in internal rotation (4.4 degrees +/- 2.5 degrees versus 2.5 degrees +/- 1.7 degrees for intact ankles, P < 0.0004) and an increase of 425% in varus (0.42 degrees +/- 0.56 degrees versus 0.08 degrees +/- 0.34 degrees for intact ankles, P < 0.003). There were no significant differences seen in plantar flexion. Based on these results, caution is advised in the indiscriminate use of medial sliding osteotomies, because this procedure may predispose the patient to premature ankle arthritis as a consequence of the altered ankle motions.     

Modified medial displacement and valgus osteotomy for unstable intertrochanteric fractures

We have described previously a modification of the medial displacement and valgus osteotomy of Dimon and Hughston to manage non-unions of intertrochanteric fractures. In this study, we have used the same modification to manage fresh, unstable intertrochanteric fractures. Eighty-seven patients underwent this procedure. Four died within 4 months. The remaining 83 patients were evaluated over a period ranging from 4 to 49 months. There was a low complication rate with this method. They included one perforation of the femoral head, one post operative infection that recurred as a deep infection, one partial superior migration of the implant, one varus fixation with noticeable shortening and two cases where the trochanteric wire had snapped. In the others, the hip movement, abductor function, functional recovery and rate of union (8-12 weeks) were good. The method permits early weight-bearing and avoids some of the problems seen with anatomical fixation of unstable fractures using the sliding screw plate. We feel that medial displacement and valgus osteotomy with an angled blade plate has a definite role in the treatment of unstable intertrochanteric fractures in some situations.     

Relation of heart rate variability and serum lipoproteins in type 1 diabetes mellitus and chronic stable angina pectoris

Extended trochanteric osteotomies have been recommended to facilitate femoral component removal, femoral cement removal, and acetabular exposure in cases of difficult revision hip arthroplasty. Complications due to the osteotomy have been rare and no nonunions have been reported when this osteotomy has been used in conjunction with extensively porous-coated implants. It has been suggested that the osteotomy should also work well with impaction grafting revisions. This is a report of two cases of nonunion of extended trochanteric osteotomies in which the impaction grafting technique was used.     

Meniscal allograft transplantation for unicompartmental arthritis of the knee

Sixty-seven meniscal allografts were transplanted in the knees of 63 patients between 1988 and 1994. Before surgery, all patients experienced refractory disabling knee pain secondary to a prior total meniscectomy with advanced unicompartmental osteoarthritic changes as verified by arthroscopy. At a mean followup of 31 months (range, 1.0-5.5 years), 58 knees (86.6%) attained a good to excellent results-Twenty-one knees received isolated meniscal allografts, with 19 achieving good to excellent results (90.5%). Five knees received a medial or lateral meniscal allograft with an anterior cruciate ligament reconstruction, and 4 (80.0%) obtained good to excellent results. Thirty-four knees received a meniscal allograft in combination with either a valgus high tibial osteotomy, varus high tibial osteotomy, or varus distal femoral osteotomy to correct for preoperative varus or valgus deformities, with 29 (85.3%) attaining good to excellent results. The remaining 7 knees underwent a combined medial meniscal allograft, valgus high tibial osteotomy, and anterior cruciate ligament reconstruction with 6 (85.7%) attaining good to excellent results. The most frequent complication was a traumatic posterior horn tear in 6 knees at a mean of 21 months after surgery (range, 9-43 months), most likely the consequence of unsuccessful healing of the posterior horn of the graft.     

Progressive opening-wedge osteotomy for severe tibia vara in adults

Five patients with tibia vara were treated with progressive opening-wedge osteotomy. The maximum varus deviation of the mechanical axis of the tibia varied from 20 degrees to 12 degrees. The minimum postoperative follow-up was 26 months. Complete correction of the deformity was achieved without any major complications. Progressive opening-wedge osteotomy offers several advantages over conventional osteotomy in adults. First, fibular osteotomy is unnecessary. Second, knee mobility is only slightly restricted immediately following surgery. Third, it is possible to adjust correction postoperatively, and finally, progressive opening-wedge osteotomy does not induce shortening of the lower limb. The most significant disadvantage is the need for prolonged external fixation. This technique should be reserved for patients with severe deformities (minimum of 15 degrees varus) and mild or moderate osteoarthrosis.     

A review of tibial lengthening procedures

Eight patients had tibial lengthening procedures according to Anderson's method. The necessity of early determination of callus formation and bone grafting, if necessary, is emphasized. The potential morbidity in this procedure is great and the parents must be made fully aware of them. As Anderson states, it is a procedure that should be reserved for the child between 8 and 12 years old with a predictable discrepancy between 4 and 15 cm. We believe it is a useful procedure in problems of unequal length of the lower limbs but should not be used whem simpler procedures such as femoral shortening or epiphyseal arrest are indicated.     

Valgus osteotomy of the humeral neck: a technique for the treatment of humerus varus

Proximal humerus varus is defined by both its radiographic and clinical characteristics. Clinically significant humerus varus has a proximal humeral neck-shaft angle less than 140 degrees and causes limited active abduction or forward flexion as a result of impingement of the greater tuberosity on the acromion. Weakness of the shoulder girdle is often present as well. The condition may be congenital, developmental, idiopathic, or posttraumatic in origin. Previous treatments for humerus varus have included acromionectomy and wedge osteotomy with placement of the extremity in a shoulder spica cast. This article describes a technique for treatment involving valgus osteotomy of the humeral neck and tension-band fixation. Correction of the deformity allows markedly improved function of the extremity with significant increases in active and passive abduction, forward flexion, and internal rotation.     

Identification of HER2/neu-derived peptide epitopes recognized by gastric cancer-specific cytotoxic T lymphocytes

Attention is drawn to the high incidence of varus angulation in the lower femur in Ollier's disease; eight of a total of 14 patients with this condition have this deformity. There may be retardation or arrest of the medial portion of the lower femoral growth plate. One case demonstrates a bone bridge, a condition not previously described in Ollier's disease. The limb-length inequality and varus angulation require concurrent management by a variety of techniques, which are described. Three of the eight patients have reached skeletal maturity; the remainder provide useful information on the condition and are a stimulus for discussion of future management.     

Perthes disease--results of a containment-oriented therapy concept

INTRODUCTION: In a retrospective study a treatment concept for Perthes' disease dependent on the containment was applied. PATIENTS/METHODS: 49 hips of 41 children (9 female, 32 male) were treated between 01. 01. 1990 and 31. 12. 1995. In our concept of treatment a varus femoral osteotomy was performed in 28 cases with not contained hips or less than 4/5 coverage of the femoral head (X-ray/MRI). The other 21 well contained hips with 4/5 coverage or more were treated conservatively with physiotherapy and in case of joint effusion and pain additionally with the use of crutches (partial weight bearing) and anti-inflammatory medication. The average age in the non-operative group at the time of first investigation was 4 years and 9 months (3 y./1 m. to 7 y./1 m.) and 6 years and 3 months (4 y/2 m. to 10 y/0 m.) at our last examination (mean follow up 17.7 months, range of 6 to 72 months). At the time of indication for a varus femoral osteotomy the patients had an average age 6 years and 1 month (3 y./6 m. to 10 y./2 m.), the mean age at the last postoperative examination was 7 years and 11 months (4 y./8 m. to 12 y./5 m.) with an average follow up of 21.5 months (6 to 77 months). RESULTS: For the conservatively treated children we achieved good results (still well contained hips with 4/5 coverage, no decrease of function, no increase of pain) in 85.7% (18 of 21 cases). In 85.7% (24 of 28 cases) we found good results (well contained hips, increase of coverage, no decrease of function, no increase of pain) in the operation group. CONCLUSIONS: The presented concept of therapy in Perthes' disease was practicable for all patients and included the possibility of decision for operative or non-operative treatment. In both groups we achieved good results in 85.7% of the cases.     

Orthopedic management of osteopetrosis: results of a survey and review of the literature

Osteopetrosis or Albers-Schonberg disease is a rare hereditary disorder of osteoclast function in which resorption of bone is diminished, resulting in abnormally dense bones. The condition is known to occur in at least four recognizable clinical patterns, each of which is variable. The optimal treatment of fractures and of bone deformity in these patients has not previously been made clear. To determine appropriate orthopedic management of the condition, we conducted a survey of the membership of the Pediatric Orthopedic Society of North America. The combined experience of 57 surgeons who treated 79 patients with osteopetrosis was compiled. Four femoral neck fractures treated by closed reduction and internal fixation had a satisfactory result, but three treated nonoperatively developed varus and required osteotomy. A total of 20 hips was treated for coxa vara by various means, none of which was free of complications. Valgus osteotomy, when used as the primary treatment for coxa vara, was the most consistently satisfactory procedure, whereas in situ pinning failed in two of three hips. Fourteen subtrochanteric fractures and 31 other fractures of the femur were treated. Good results were reported with traction or casting or both in the majority of those fractures. Twenty-nine tibia fractures were treated successfully, the majority by nonoperative means. Upper extremity fractures healed well with closed reduction and casting. Vertebral fractures, spondylolysis, and back pain were most frequently treated without surgery.     

Immunologic aspects of Helicobacter pylori infection and malignant transformation of B cells

We studied the use of overhead traction in the treatment of congenital dislocation of the hip in thirty-five children (fifty hips) whose mean age at the time of the diagnosis was thirty-three months (range, eighteen to seventy-two months). None of the children had had any previous treatment. The mean time in traction was twenty-three days (range, eight to thirty-six days). Closed reduction was successful for relocation of the femoral head in thirty-eight of the fifty hips; twenty of these hips needed no additional treatment, sixteen were treated with an innominate osteotomy because of severe acetabular dysplasia, and two needed femoral derotation and an innominate osteotomy to correct persistent subluxation. In the remaining twelve hips, closed reduction failed at the outset and an open reduction was necessary. Femoral shortening also was performed in seven of the twelve hips to maintain concentric reduction. After a mean duration of follow-up of forty-eight months (range, thirty-two to sixty-five months), thirty-three hips were rated as class 1; seven, as class 2; four, as class 3; and five, as class 4, according to the criteria of Severin. The remaining hip could not be so classified. Avascular necrosis developed in two hips that had been treated with closed reduction followed by Salter osteotomy and in three hips that had been treated with primary open reduction. We found that preliminary overhead traction facilitated closed reduction of untreated congenitally dislocated hips in children who were eighteen to seventy-two months old.     

Transtrochanteric rotational osteotomy for osteonecrosis of the femoral head. 43 patients followed for at least 3 years

We reviewed 48 hips in 43 patients 3-7.1 years (average 4.6 years) after Sugioka transtrochanteric rotational osteotomy for osteonecrosis of the femoral head. The average age at operation was 41 years. Thirty-four patients were men and 9 women. Overall results at the final follow-up were satisfactory in 30 hips (62%). Kaplan-Meier's survivorship was 62% at 3 years and 60% at 5 years postoperatively. Six hips for which the ratio of the intact area of the articular surface on the preoperative lateral radiograph was less than 30% showed further collapse. Five hips were converted to bipolar hemiarthroplasties or total hip arthroplasties. Complications, such as varus deformity, subtrochanteric fracture, and ectopic bone formation, occurred in eight hips. Five of them were operated on in the first 2 years of this series. Three of these five operations had unsatisfactory results. We conclude that satisfactory results can be achieved using this osteotomy by maintaining exact surgical technique and by limiting the surgical indications to hips with an intact area of more than one-third of the entire articular surface on the lateral radiograph of the femoral head.     

A quantitative pharmacological study of the cholinergic depolarization of hippocampal pyramidal cells in rat brain slices

Twenty-eight unicompartmental knee arthroplasties performed as an alternative to high tibial osteotomy or tricompartmental knee arthroplasty in patients under 60 years of age were reviewed after 2 to 6 years of follow-up. The patient's age at the time of operation averaged 52 years. Using the Knee Society Score, 90% were rated good or excellent results in terms of function and pain relief. The average flexion angle obtained was 124 degrees, and the average postoperative alignment was 4 degrees of anatomic valgus for varus deformities and 8 degrees for valgus deformities. The average activity level according to the Tegner and Lysholm score slightly improved (preoperative, 2.3; follow-up, 2.7 points). Of the 28 knees, 9 (32%) presented radiolucent lines about the tibial component and two had incomplete radiolucent lines at the bone-cement interface on the femoral side. There was no correlation between activity level and tibial radiolucent lines. Two revisions were performed because of loosening of the femoral component at the prosthesis-cement interface. One was converted to another unicompartmental arthroplasty and the other to a tricompartmental arthroplasty. One tibial component exhibited an asymptomatic slowly progressive radiolucency. Unicompartmental knee arthroplasty in middle-aged patients yields 2- to 6-year results competitive with osteotomy but inferior to tricompartmental arthroplasty in terms of revision. The specific prosthetic design used in this series appeared to be vulnerable to femoral component loosening possibly because of constrained tibial topography and smooth tapered femoral fixation lugs.