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In 1948 Jaffe and Lichtenstein published a series of bone tumours as chondromyxoid fibromata, stressing that this newly recognised entity was likely to be mistaken for chondrosarcoma but was a benign growth. The accumulated experience of thirty-seven cases, which are all that have been recorded in detail, is briefly reviewed. A further series of nine similar cases is reported here and comparisons are made which show general agreement with the experiences and conclusions of earlier authors. It is however suggested that the tendency to recur may have been underestimated, particularly in younger patients.
Two cases of malignant angioblastoma of tibia are described, one finally treated by amputation and the other by segmental resection and grafting. They have remained free from signs of local recurrence or distant metastasis for five and a half and ten and a half years respectively. Both showed prominent areas of neoplastic mesenchymal angioblastic tissue which closely imitates solitary fibrous dysplasia.
The natural history and radiological characteristics of these little-known tumours, long thought to be "adamantinoma" of bone, are described.
The infrequency of serious cartilage destruction in the joints of children makes it probable that the majority will recover with antibiotic and constitutional treatment alone, especially if a joint biopsy is performed. Synovectomy for children should therefore be reserved for those whose knees remain swollen and warm, even after antibiotic therapy, or whose range of movement does not show signs of returning. Exploration of such joints may show that pannus is wholly or partly covering the cartilage and that it is soft and pitted. Removal of the pannus allows better nutrition of the cartilage. The number of children who require arthrodesis in the future should be very small.
Adults who respond well to antibiotic and constitutional treatment may also recover without surgery, except biopsy, but for patients with more severe disease the need for an alternative to arthrodesis exists. The choice between synovectomy–better called joint clearance –can often only be made after the joint has been opened. The choice between the two operations has always been fully discussed with the patient before the operation. The results enumerated in this paper suggest that arthrodesis may only need to be performed for patients with severe disease, often involving the bony articular surfaces, and that joints may recover function even when there has been partial destruction of cartilage.
1. A study of the average rate of growth of the legs and trunk of 202 normal average maturing children is presented.
2. The annual growth of the limbs and trunk was related to the skeletal age of each child, and the increments of growth per skeletal year subjected to statistical analysis.
3. Methods of growth prediction of leg length and mature height have been derived and the practical application of the investigation to orthopaedic surgery is discussed.
1. Thirteen years of experience in charge of treatment in a Residential School for Cerebral Palsy, and a review of 466 operations performed on children handicapped by this condition, form the basis for this attempt to frame the indications and contra-indications for operation.
2. A brief description is given of the more commonly performed operations, with an indication of the results that are likely to be obtained.
3. Orthopaedic surgery has a worth-while contribution to make in the treatment of cerebral palsy. When the cases are selected with care, when the appropriate orthopaedic measures are skilfully performed and when the patients are adequately supervised afterwards, the benefits of surgery are greater than those provided by any other treatment, and they are achieved more quickly.
4. The desire to improve and the "inner urge" of the patient to succeed may be the most important single factor in his rehabilitation.
1. The authors have found epiphysial stapling a satisfactory and helpful procedure for correction of limb length discrepancy and recommend its use as described.
2. The use of a spring caliper for absolute radiographic location of the epiphysial plates and the use of two Vitallium staples each side is recommended.
3. Suggestions for avoiding injury to the epiphyses are outlined.
4. The experience of stapling operations in seventy children is reported. Forty-four of these patients have completed growth.
It is concluded that the development of scoliosis is due to muscle imbalance, the weaker muscles being on the convex side of the curve. It is suggested that the increased electrical activity in the muscles on the convex side is secondary to the scoliosis, being part of the body's attempt to compensate for the curvature.
1. A patient is described who developed hypothermia shortly after being rendered tetraplegic by a fracture of the cervical spine.
2. The causes and prevention of hypothermia or hyperpyrexia in tetraplegia are discussed.
1. Two cases of rupture of the axillary artery without dislocation of the shoulder or fracture of the neck of the humerus are reported, and the etiology is discussed.
2. The treatment of a ruptured axillary artery is primary repair, and not ligation.
3. In the repair of the artery the complete clearance of distal thrombus is most important; retrograde flushing is advised for this purpose.
1. A case is described ofcomplete rupture ofthe second part of the axillary artery complicating anterior dislocation of the shoulder in a woman aged fifty years.
2. Interesting features were that the patient was comparatively young, that the rupture was a result of the dislocation and not of the reduction, that the axillary vein remained intact, and that a satisfactory circulation returned after ligation of the artery.
1. Rupture of the brachial artery or of one of its divisions in association with elbow injuries is probably more common than a survey of the literature would imply. Three cases of rupture of the brachial artery complicating compound dislocation of the elbow are reported.
2. These cases appear to have a consistent pattern of soft-tissue damage, with avulsion of the common flexor origin, and a varying degree of damage to the biceps and brachialis. The median nerve escaped injury.
3. The method of dealing with the divided vessels does not appear to be of importance in determining the outcome, simple ligation being as satisfactory as attempts at grafting or suture.
4. In no case was there any evidence of Volkmann's contracture. Provided rapid reduction of the dislocation is effected, together with ligation of the vessels, a satisfactory return of the circulation may be expected.
1. Two of the three metals at present in use in orthopaedic surgery have been studied to assess their tendency to cause wound reactions.
2. Cobalt-chrome alloy proved to be the better, the incidence of obligatory plate removal being at most 3 per cent. Visible corrosion in this metal never occurred.
3. 18/8 Mo stainless steel proved to be the poorer, the incidence of obligatory plate removal being 20 per cent. Visible corrosion of the metal is estimated to have occurred in about 5 per cent of screws inserted.
4. Regardless of such accelerating factors as metallic transfer, 18/8 Mo steel may have to be accepted as inherently more susceptible to corrosion than is cobalt-chrome alloy.
5. The qualities of two other stainless steels also became evident. Previous work describing the very bad situation arising from the use of EMS was confirmed. By contrast, a steel that was in use before 1951 gave little trouble. This steel was probably FSL.
1. The antigenicity of cancellous bone has been investigated in ninety-seven rabbits.
2. The immune responses of lymph nodes draining fresh homografts of cancellous bone (Burwell and Gowland 1961
3. The principal antigenic component of a fresh homograft of iliac cancellous bone is the nucleated cells of the red marrow.
4. Homologous marrow-free cancellous bone does not usually produce cytological evidence of an immune response in the lymph node draining the graft, unless new homograft bone formation occurs.
5. The treatment of marrow-containing cancellous bone by boiling, freezing at - 20 degrees Centigrade, freeze-drying, irradiation or by merthiolate solution impairs the transplantation antigenicity of the tissue as a homograft.
6. The immersion of cancellous bone in a glycerol-serum-Ringer solution which is then slowly cooled to - 79 degrees Centigrade, stored for one week and then rapidly thawed, allows considerable preservation of the antigenicity of the red marrow.
7. Knowledge concerning the antigenicity of fresh and treated homologous bone is discussed.
8. Evidence is presented to show that the large and medium lymphoid cell response of lymph nodes draining homografts is due principally to the T-antigens, rather than H-antigens, of the grafts.
9. The changes which occur in the first regional lymph nodes draining tissue homografts may provide another test system to assess the transplantation antigenicity of foreign tissues or extracts of foreign tissues other than bone.
1. Homografts of eighteen-day-old foetal femora in pure strains of mice showed no fundamental difference in behaviour from grafts of more mature bone and cartilage.
2. Growth of bone was limited to a short period after transplantation and was abolished by previous immunisation. Cartilage growth alone was responsible for the increase in size of these transplants and did not appear to be influenced by the presence of immunity.
3. There is no reason to suppose that bone from an immature source is likely to behave more favourably than more mature bone homografts in clinical use.
4. The limited growth of cartilage and the total failure of bone survival in the heterografts indicate an immune reaction ofa different order from that which develops against the homograft.
5. The different effect of the homograft immune reaction on cartilage and bone enabled certain conclusions to be drawn concerning the part played by these two tissues in determining the form of a bone. Cartilage growth and development is shown to be regulated in large part by intrinsic factors. Bone growth and form on the other hand is shown to be dependent largely upon extrinsic influences.
1. In the experiments undertaken autogenous vesical mucosal transplants were made in guinea-pigs. The transplanted mucosa proliferates and forms a nodule. Central necrosis of the nodule and the secretion of the proliferating epithelium combine to form a cyst filled with a viscous fluid.
2. Before the cyst is well defined some of this fluid diffuses into the sub-epithelial connective tissue, producing areas of tissue oedema which later are transformed into translucent hyaloid islands. With further condensation of the collagen fibres, these areas are converted into primitive bone. The hyaloid islands act as a bone precursor. Bone always formed in the wall of the cyst within thirty days except in cases of sepsis or death of the transplant, when there was no osteogenesis. Homografts of vesical mucosa were found unreliable in their capacity to induce bone.
3. The results of the histochemical investigation and radiographic diffraction of the hyaloid areas suggest that the proliferating mucosa is the source of the inducing agent.
4. Bone can be induced only in sites where a primitive vascular connective tissue is growing and where there exists an adequate blood supply.
5. The rapid rate of osteogenesis can be seen in the radiographs of induced bone in radial defects. The electron-microscopic study of the induced bone at three weeks confirmed that osteoid had been formed so quickly that calcification had not yet taken place.
6. The relationship between the bone induced by transplanting vesical epithelium and the formation of urinary calculi is discussed and their common origin postulated.
Continuous strontium administration first induces typical "rickets" in young rats receiving adequate calcium phosphorus and vitamin D but later the widened cartilage spontaneously calcifies intermittently leaving transverse bands consisting largely of osteoid tissue in the metaphysis; in addition to intermittent calcification bone changes indicate that skeletal growth is not uniformly progressive.
Subsequently areas of the epiphysial cartilage fail to calcify and localised defects develop; among these are wedge-shaped metaphysial osteoid tissue masses, "invagination" of the epiphysial plate to form multiple nodules of cartilage with proliferating cells in the middle and hypertrophic ones at the periphery, perforation and fragmentation of the epiphysial plate with formation of large cartilage nodules. Multiple cartilage nodules of different sizes appear in the epiphysis, metaphysis and bone shaft.
Most bone margins are lined by osteoid seams which only slowly calcify and concomitantly resorption is decreased so that the rate of remodelling of the skeleton is diminished. This type of process may help to explain the results of treatment of osteoporosis by strontium administration.
November 1961,
