138

Following arterial repair, distal pulses always returned; some were delayed for as long as 3 days. Patency at the site of anastomosis was demonstrated in all cases by arteriograms.

After nerve suture (both primary and secondary) the ability to distinguish between a sharp and a blunt object always returned. Normal two-point discrimination returned in 3 patients within 30 months. Digital flexion returned in all patients. However, the ability to rotate the thumb to a posi- tion adequate for grasp was restored in only I patient.

Damage to the hand by heat during nerve regenera- tion occurred in about half of the patients. The other notable complication was the development of a grasp pattern that excluded the index finger.

Injury INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY Oct. 1971

This persisted in some patients after the ability to flex the digit actively had been restored. Tendon transfer was effective in restoring thumb rotation in those patients in whom it was lost. Early tendon transfer should be considered in all these patients to minimize the development of poor grasp patterns and to restore optimal hand activity as early as possible.

Restoration of a Functional Prehension in Patients with a Cervical Spinal Cord Injury by means of Orthoses: GOTTLEIB ZRUBECKY, Austria

Zrubecky showed the high technical standard of the mechnical aids provided in Austria for the victims of tetraplegia.

P.S.L.

O R T H O P A E D I C S U R G E R Y

Eighteenth Congress of the South African 1971

The Blood-supply of the Lumbar Spine and its applica- tion to the Technique of lntertransverse Lumbar Fusion: D. DALL and I. MACNAB, Cape Town and Toronto

Dall and Macnab used intertransverse fusion for painful instability of the lumbar spine, having used discography to show the extent of fusion neces- sary. Previous dissections, using corrosion casting had shown that there were two arteries just lateral to the zygapophyseal joint line and one more just lateral to the pars interarticularis. If these were avoided there was much less bleeding.

Halopelvic Traction for the Correction of Spinal Curves: A. R. HODOSON, Hong Kong

Although halopelvic traction has been developed in order to correct scoliosis it can also be used to correct deformity resulting from injury and it can be worn over a year if necessary. Inserting the pelvic pin requires suitable apparatus and a clear understanding of the anatomy of the area.

Recurrent Posterior Dislocation of the Shoulder: H. B. BOYD, Campbell Clinic, U.S.A.

Only about 2 per cent of recurrent dislocations were posterior. Some followed injury, others could be ascribed to loose joints, in which case they affected both shoulders and were found more often in women than in men. Dislocation should not be operated on if the patient is able to cause and correct it volun- tarily. McLaughlin's operation should be used for long-standing dislocations with much-deformed heads. Otherwise the tendency of the long tendon of biceps brachii to press the head backwards and downwards should be removed by cutting the tendon and stap- ling it to the back of the neck. The operation had been performed succe.ssfully 11 times on 10 persons.

The Assessment of Progress in Osteomyelitis: E. E. G. LAUTENBACH, Johannesburg

The usual diagnostic criteria could be misleading. In 20 per cent of cases no growth was obtained from swabs. Only 54 per cent of first swabs were

Orthopaedic Association, held in Johannesburg, June,

positive; the percentage rose to 80 if four swabs were examined. Blood-culture was persistently negative in just over one-third of acute infections. The white count did not exceed 10,000 per c.mm. in 60 per cent of cases. The E.S.R. was raised in 80 per cent of acute cases but in only 50 per cent of the chronic ones.

Antistaphylococcal titres rose early in acute disease but were of no value for assessing progress in chronic cases. In short, simple signs such as local warmth and swelling were as reliable as those investigated but healing of sinuses did not mean that the disease had been cured. Antibiotics should be continued for I month after all signs of activity have gone, but not for more than 4 months.

The Prevention and Management of Thrombo- embolism: P. S. LONDON, Birmingham

Phlebography, radio-iodinated fibrinogen, and post-mortem dissection of the venous tree have shown that even the most vigorous application of conventional methods to prevent venous thrombosis fails in at least one-quarter of cases. Electrical stimu- tion of the calf during operation may be of value. The proven success of phenindione and warfarin depends on their being started in time and is limited by any undue tendency of the patient to bleed; there may also be difficulty in stabilizing dosage.

Once thrombosis has occurred, which happens about twice as often as there are physical signs of it, most thrombi can be dispersed in time by the use of anticoagulant drugs. Streptokinase is best reserved for acute and dangerous conditions such as phlegmasia caerulea dolens. Thrombectomy is disappointingly often followed by fresh thrombosis. Ligation of the inferior vena cava is of questionable value. Pulmonary embolectomy should be considered when there is no time to institute medical treatment or if such treatment does not lead to improvement.

The Prevention and Treatment of Painful Amputation Neuromata: S. L. BIDDULPH, Johannesburg

All neuromata showed similar histological feat~es, but if the nerve-ends were stitched into snugly fitting

Volume 3 REPORTS OF Number 2

silicone rubber caps the nerve-fibres were neatly arranged in parallel lines. If the cap was too short the fibres showed the familiar tangled arrangement. The longer the cap the more ischaemic change was found in the nerve-ends.

Spontaneous Fractures in Spina Bifida: J. E. I-IANDELS- MkN, Johannesburg

Eleven of 77 persons with spina bifida suffered 35 fractures that were mostly close to the epiphyses. The most likely explanation for them was that they were art effect of leverage by natural forces on bones weakened by decalcification, with the massive callus that develops when movement occurs at a fracture of bone that is active in repair. The patients' callipers were the best splints but corrective osteotomy was sometimes required.

Osteomyelitis in Gaucher's Disease: S. SACKS, Johannesburg

Gaucher's disease depends on an autosomal recessive gene; it occurs in about 1 person in a million in Britain and in about 1 in 30 among the Ashkenazi Jews in South Africa. It is characterized by the flask- like shape of the lower half of the femur and by an increase in the tartrate-stable fraction of serum acid phosphatase. Acute osteomyelitis can be mimicked by ' pseudo-osteitis ' or Gaucher's bone crisis, which should not be operated on. True infection was likely to become widespread within the bone and was very difficult to eradicate.

Pseudochondromalacia of the Patella: E. J. NANGLE, Salisbury

Painful knees in young and active persons may occur because the patella presses on synovial mem- brane above its normal bearing surface of the femur. This abnormally high position will go unrecognized unless a lateral radiograph of the knee is made with the joint fully extended and the quadriceps contracted.

The Scope of Organ Transplantation and Immuno- suppression: J. A. MVBURGH, Johannesburg

Myburgh reviewed the world's records of organs that had been transplanted, among which the kidney stood well ahead of all other organs put together. From 70 to 80 per cent of kidneys from living donors were still acting after 2 years. The present hope of inducing tolerance to a specific organ has had some encouragement from recent developments. It is at present still necessary to use immunosuppressive drugs, such as azothioprine and prednisone.

Necrosis of the Femoral Head after Organ Trans- plantation: R. L. CRUESS, Montreal

Cruess reported a study of 77 recipients of kid- neys at least 6 months previously. Thirty patients had developed avascular necrosis and 14 had developed collapse of the head of the femur. A similar number of persons had shown similar changes in the shoulder, knee, and ankle.

The first radiological sign was subchondral rare- faction and this was followed by collapse. The cartilage was found to be unsupported by bone in some places and the loss of bone was sometimes extensive. Although the cartilage was itself largely acellular it had been known to become concrescent with

MEETINGS 139

bone once more; living bone could be deposited on the existing dead framework. The condition closely resembled osteochondritis dissecans and though it was found most often in joints that bore a great deal of weight it had occurred also in the shoulder.

Steroids had been given and there was thought to be a special relevance of the large increases of dose that were made to overcome rejection. However, a combination of fatty liver, fat emboli in the bone- ends, and fatty inclusions in the osteocytes seemed to offer a clue to the reason for the previously re- ported association with alcoholism.

Drug-induced Arthropathy with Necrosis of the Femoral Head: L. SOLOMON, Johannesburg

Solomon described joints that had been severely damaged; 22 patients had received steroids, 14 showed evidence of fatty overload, 12 had received analgesic drugs, and 10 were alcoholics. Unlike Cruess, he had found that the acetabulum as well as the head of the femur could give way but he had observed both subchondral ossification, and fat in the blood- vessels. The consolidation was caused by the smashing up of the bony trabeculae. Arthropathy could also occur with the condition of iron-overload. The liver contained large quantities of iron and in no way resembled the alcoholic's. Fat was not found in the blood-vessels of the head of the femur whereas it was found after fracture of the neck of the femur, and experimental injection of fat had been found to kill bone.

In discussion it was emphasized that radiological diagnosis required knowledgeable interpretation of special films; given this, Cruess had known radiological signs to precede symptoms by a year, and the fact was that occasionally a person had his life extended by another's kidney at the cost of crippling disability.

The Fate of Exposed Bone: D. H. WALKER, Johannes- burg

It is commonly accepted that every effort should be made to cover exposed bone, the more so if the exposed area includes an articular surface. With babies even these surfaces can spontaneously become covered by skin.

Bone exposed for a few minutes, or even a few hours, denuded of its periosteum, does not generally die; longer periods are harmful.

This paper discusses the possibility of a critical period of bone exposure and outlines the common plastic and reconstructive surgical techniques of providing safe bone cover in various regions.

Autogenous Osteocartilaginous Grafting in Severe Lesions of the Knee: A. S. PALAZZI, Barcelona

The author described a personal approach to some destructive lesions of the femoral condyles. The affected area is widely resected and replaced by an osteocartilaginous graft taken from a non-weight- bearing zone, usually the lateral patellar surface of the femur. These grafts seemed to survive. Of 23 persons operated on 21 had no pain and 21 regained not less than 90 ° of flexion at the knee-joint.

In discussion, the speaker said that he did not know what was the risk that these patients would develop a condition resembling chondromalacia patellae.

140 INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY Injury Oct. 1971

Massive Osteo-articular Bone-grafts: C. E. OTTO- LENGHI, Buenos~Aires.

Massi~'e bbrw~ra/ts after resection of large osteo-articulai" .le.~Ohs had been employed in 70 cases. Fiftenat~t0genous and 55 homogenous grafts were used. Failure may occur due to infection, reabsorption, or non-union of the graft. Local recurrence of the original tumour or later metastatic lesions may imperil the graft.

The indications for massive osteo-articular graft- ing are limited; it has a valuable place where alterna- tive mutilating procedures are undesirable. One of the most interesting features of the cases reported was that in some the graft did not bear on the femur. In spite of this, the knees seemed to have retained their stability.

Reconstruction of the Knee Epiphysis by Pedicled Patella: R. MERLE D'AuBIGN t~, Paris

When a femoral condyle or a tibial tuberosity is destroyed by trauma or removed for tumour or

infection, reconstruction of the knee is generally obtained by means of arthrodesis. No partial prosthesis for a femoral condyle or tibial tuberosity has been proposed up to now. Homogenous cadaveric grafts unite but are bound to collapse after a time.

The patella, kept alive by a musculovascular pedicle, was used to reconstruct femoral condyles and tibial tuberosities. In all cases a mobile and stable knee was obtained and preserved for from 2 to 20 years. Operative technique was demonstrated, as well as selection of patients and analysis of results.

The raw surface of the patella was placed against cancellous bone and the tendinous surface was used as the bearing surface. In spite of the extent of the operation, which was for injury in 3 cases and for tumour in 7, the patients regained nearly 90 ° of movement and those shown in a film walked as well on stairs as on the fiat.

P.S.L.

LETTER TO THE EDITOR

F E M O R A L S H A F T F R A C T U R E S IN P A G E T ' S D I S E A S E

From Mr. M. Grundy Sir,

The treatment of fractures of the femur in Paget 's disease is a subject on which divergent opinions exist. I would take issue with both Mr. London ' s letter (INJURe, 2, 304) and with the appended editorial comment.

Internal fixation is mandatory only where reduction cannot be achieved and maintained by closed methods, as in the subtrochanteric frac- tures of Paget 's disease where flexion and abduc- tion of the proximal fragment occurs. In this situation a short Kuntscher nail is sufficient to control angulation whilst external splintage controls rotation. Attempts to insert long full- diameter nails complicate the operat ion un- necessarily. Intentional perforation of the lateral cortex as advocated by Mr. London

creates a weak area at which subsequent fracture can and does occur.

In fractures of the shaft, internal fixation, whether by nail or compression plates, has the disadvantage that the bowing which predisposed to fracture is unchanged. I have shown (Grundy, 1970) that conservative treatment on a Thomas splint can produce union with correction of deformity. It has not been demonstrated that internal fixation confers any compensatory advantage either in terms of reduced morbidity or in speed or incidence of union.

GRUNDY, M. (1970), 'Fractures of the Femur in Paget's Disease of Bone ", J. Bone Jt Surg., 52B, 252.

Yours faithfully, M. GRUNDY

Consultant Orthopaedic Surgeon Royal Infirmary, Blackburn, Lancashire BB2 3LR. 8 July, 1971.

N O T E S A N D N E W S

The British Society for Surgery of the Hand The British Society for Surgery of the Hand will

hold its annual Instructional Course at the Maurice Bloch Theatre, Royal College of Physicians and Surgeons, 242 St. Vincent Street, Glasgow, on Friday 12 Nov., 1971, from 9.30 a.m. until 5 p.m. The following main topics will be covered:

1. Tumours of the Hand. 2. Dermatological Problems in Hand Surgery. 3. Surgical Neuromuscular Disorders. 4. Peripheral Vascular Problems. The registration fee, including lunch, etc., is £5.00.

Cheques should be made payable to ' T h e British

Society for Surgery of the Hand '. Applications to attend this meeting, which should include the registra- tion fee, should be addressed to The Honorary Secretary, British Society for Surgery of the Hand, Royal College of Surgeons, Lincoln's Inn Fields, London WC2A 3PN from whom further details can be obtained.

Chair of Orthopaedic and Accident Surgery Mr. J. S. Ellis, M.Chir., F.R.C.S., has been

appointed to the new chair of Orthopaedic and Accident Surgery in the University of Southampton.