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This retrospective study summarizes experience with 135 secondary alveolar cleft bone graft procedures over 8 years. The overall success rate was 83.7%. The group of patients (n = 108) that had particulate cancellous bone and marrow obtained from the iliac crest as donor bone had an 89.8% success rate. The group (n = 27) that had calvarial bone as the donor material had a success rate of only 63%. It is felt that inferior results with calvarial bone are probably related to the procurement technique. In both the iliac crest and calvarial groups, there was a trend toward declining success rates with advancing age of the patient. Morbidity associated with these procedures, consistent with other reported series, was low.

Duplex scanning with a combination of real-time and Doppler ultrasound is a noninvasive procedure used for the detection of deep vein thrombosis. The technique is described, its use in orthopaedic patients is discussed, and a plan of treatment based on duplex results is reported.

One hundred consecutive orthopedic long bone fracture patients requiring surgical fixation were nutritionally assessed using both the nutritional index of Rainey-MacDonald et al. and total lymphocyte count. The ability of these two parameters to identify correctly those patients who do and do not develop postoperative complications was assessed using several error rate measures, which included sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Fourteen of our patients developed postoperative complications. All complications observed were infections. The accuracy of the nutritional index and total lymphocyte count in predicting patient outcome was 78 and 51%, respectively. The positive and negative predictive values calculated for the nutritional index were 36 and 94%, respectively. Total lymphocyte count analysis resulted in positive and negative predictive values of 15 and 87%, respectively. In our sample of patients, the nutritional index was a better predictor of patient outcome than total lymphocyte count, as indicated by the higher accuracy rate calculated for the nutritional index. Based upon positive predictive value results, neither of these indicators was most accurate in identifying patients who did develop infections. Not unexpectedly, both indicators were best in identifying those patients who did not develop postoperative infections.

One hundred sixty-one porous-coated Universal (Biomet Inc, Warsaw, IN) total hip arthroplasties were performed and studied preoperatively between July 1986 and June 1989. The study included 59 men (38 at 1-year follow-up; 21 at 2-year follow-up) and 91 women (60 at 1-year follow-up; 31 at 2-year follow-up). The average age was 62 years at 12-month follow-up and 64.7 years at 24-month follow-up (range 28 to 90 years). Three groups of patients with components were evaluated both clinically and radiographically: uncemented femoral and acetabular components (group 1); cemented femoral stems and uncemented acetabular components, ie, hybrid total hip arthroplasties (group 2); and revision total hip replacement arthroplasties (group 3). Clinical results for all groups showed Harris hip scores of 87 at 1-year follow-up and 89 at 2-year follow-up. Moderate to no limp occurred in 93% of patients at 1-year follow-up and 95% at 2-year follow-up. No ambulatory aids were used by 43% of patients at 1-year follow-up or 47% at 2-year follow-up. Both walking distance and endurance improved over time. Anthropometric analysis showed no progressive lucencies around the femoral or acetabular component in either group. A Kaplan-Meier survivorship analysis could not be used, because there was only one failure. This eliminated a comparison group for those lost to follow-up. Early clinical and radiographic results have been encouraging; however, long-term analysis is needed to accurately assess the success of this total hip arthroplasty system.

In a recent 2-year period, 89 fine-needle aspiration biopsies (FNAB) were performed on head and neck lesions in 81 patients from 6 to 97 years of age. Eighty-four of the FNABs were considered diagnostic. Thirty of the aspirates were diagnosed as benign whereas 54 were diagnosed as malignant. Three specimens were suspicious for malignancy, and 2 specimens were considered nondiagnostic. The most common malignant diagnosis was squamous cell carcinoma, which involved 32 of the specimens. The most common benign diagnosis was pleomorphic adenoma. Subsequent surgical biopsy specimens were available in 45 of the patients. Of these, 41 were consistent with the FNAB diagnosis, whereas 4 were not.

A clinical study evaluating the use of calvarial (two different techniques of harvest) versus iliac donor bone in secondary unilateral alveolar cleft reconstruction based on clinical and radiographic assessment was conducted. Both iliac bone and the Hudson brace harvested calvarial bone resulted in high rates of radiographic evidence of osseous continuity between the maxillary segments and clinical resolution of the alveolar cleft defect. Calvarial bone obtained with the craniotome had a lower rate of success that was statistically different from the other two groups. The utilization of calvarial bone and the implications of harvest technique on graft transfer biology are discussed.

A prospective preoperative and postoperative venographic study of hip fracture patients has documented a significant preoperative prevalence and postoperative incidence of thromboembolic disease. A statistically higher incidence of deep-venous thrombosis is observed in patients with femoral neck fractures compared to patients with intertrochanteric fractures. A 9% (15 of 176) preoperative prevalence and an 11% (12 of 108) incidence of new postoperative thromboembolic disease were detected. There was a predilection for deep-venous thrombosis in the injured extremity compared to the noninjured extremity both preoperatively and postoperatively.

The authors previously described a method of windowing the femur that allowed good exposure for femoral cement removal and provided for reconstruction of the defect. Since that report, they have developed instrumentation to facilitate windowing of the femoral shaft. They describe its use in this report.

A review of our experience in total joint arthroplasty revealed that the cell saver was not cost-effective in the case of routine primary hip or knee replacement. Its use should be restricted to cases of revision hip and knee surgery in which infection has been ruled out. Preoperative aspiration remains the most reliable method for accomplishing this. However, if the aspiration is negative and the intra-articular fluid obtained at the time of surgery is suspicious for infection, either in appearance or on Gram stain or cell count, it is best to abandon use of the cell saver. Predonation should be routine for all hip replacement cases unless there are specific contraindications. In general, there is good acceptance of this program by patients, although a few have specifically indicated they would prefer to run the risk of homologous transfusion. Two units available for primary replacement are more than ample. In cases of revisions, a first revision justifies a minimum of 3 units. For complex revision cases involving patients with three or more previous procedures on the hip, or those requiring significant bone resection or large segment grafting, the maximum possible number of units should be obtained. Autologous blood reinfusion should be done for essentially the same indications as homologous transfusion even though risks are sharply reduced. The local source for autologous collection will then follow its own specific protocol for the disposition of remaining units. In every case, the surgical technique should be careful and directed toward limiting intraoperative blood loss.

The purpose of this study was to compare a traditional two-step method of preoperative skin preparation using aqueous iodophors with a one-step method using an iodophor-in-alcohol solution. Sixty patients having clean total joint surgery were randomly divided into two preoperative skin preparation groups (30 in each). In one group, the skin was prepared with a traditional five-minute aqueous iodophor scrub followed by the application of an aqueous iodophor solution as a paint. In the other group, the skin was prepared with a one-step application of a water-insoluble iodophor-in-alcohol solution applied as a paint. Bacterial colony counts were made by sampling the incision area with culture plates before skin preparation and just prior to wound closure. The one-step application of a water-insoluble iodophor-in-alcohol solution was equally as effective as the traditional scrub-and-paint preparation in reducing the number of bacteria about the operative site. The water-insoluble preparation also resulted in significantly improved drape adhesion as compared to the standard scrub-and-paint procedure. The one-step water-insoluble iodophor-in-alcohol solution fulfills the requirements for an operative site skin preparation and significantly improves drape adhesion. It is more convenient, easier to apply, less time consuming, and potentially less expensive than the traditional scrub-and-paint method.

In summary, reduction of blood loss and coincidental decrease in the number of blood transfusions is now of paramount importance in orthopaedic surgery. Methods to reduce blood loss include preoperative planning, hypotensive anesthesia, and meticulous surgical technique. If transfusion is necessary, autologous replacement is always preferable. Overall, the goals in blood conservation in surgery are first to decrease the amount of blood lost, and second to be sensible in replacement of this loss.

Classification of femoral neck fractures is important for prognostication, choice of treatment, and evaluation of end-results. The vitality of the patient, the configuration of the fracture, the quality of the bone and the accuracy of the reduction are important considerations. Aids in their evaluation have been presented.

The authors present two cases involving complete rupture of the Achilles tendon. Pertinent anatomical considerations and probable pathogenesis are discussed. Surgical treatment produced excellent results.

This article reviews the complexity of the microbiological environment of odontogenic infections. With an understanding of the organisms involved, the appropriate antibiotic can be chosen. A review of current antibiotic choices and the rationale for their selection is also presented.

Osteoarthropathy associated with thalassemia minor is rare. The arthritic changes are usually thought to be secondary to bone infarction or erythropoiesis, with decreased trabeculation of the femoral head followed by microfracture and arthritic changes. This report presents the radiographic changes in the hip of a patient with thalassemia minor and discusses the etiology.

Three hundred fifty-eight patients undergoing total hip arthroplasty, total knee arthroplasty, and hip fracture repair were given preventive antibiotics 20 minutes before surgery; administration of antibiotics was continued for either 24 hours or seven days. The 24-hour group (186 operations) had three (1.6%) deep wound infections. The difference in infection rates between groups was not significant.

Eleven patients on prolonged tube feedings were introduced to oral feedings in a 2- to 3-week inpatient feeding program. All but one patient successfully made the transition to full oral feeding in this period with minimal disruption of family life and parental anxiety. The program depends on proper selection of oral feeding candidates, preparation of the patient prior to hospital admission, and a firm, consistent approach to overcoming the child's resistance to eating food. A case study, overall results of the program, and management steps are described.

A patient with known factor XII deficiency underwent extraction of four impacted third molars. Significant preoperative laboratory values included a partial thromboplastin time (PTT) of greater than 100 seconds and a factor XII level of less than 1%. The third molars were removed without any significant intraoperative or postoperative bleeding. Factor XII not only has an important function in the initiation of the intrinsic pathway of the coagulation cascade, but it also plays a significant role in complement activation, kinin generation, and fibrinolysis. It would seem that a deficiency in this factor would have widespread clinical implications. In fact, the only clinical significance seems to be a predisposition to thromboembolism in factor XII deficient patients.

To determine the rate of physician and dentist compliance with the American Heart Association's (AHA) recommendations for prophylaxis against bacterial endocarditis--considered the standard of care--questionnaires were mailed to 1,131 dental and medical practitioners. They were asked to identify various cardiac conditions requiring prophylaxis and dental procedures that would cause a bacteremia, and to write prescriptions for prophylactic antibiotics for five different scenarios. Both groups had low compliance with AHA recommendations (32.9% collectively) when prescribing appropriate antibiotic regimens for bacterial endocarditis prophylaxis.

Arthrography is a proven and well-established diagnostic aid in the evaluation and treatment of lesions in several joints; it provides useful information in the treatment of shoulder and wrist lesions. The procedure can be used whenever the cause of shoulder pain is in doubt. Arthrography of the shoulder can aid in the diagnosis of a variety of lesions: rotator cuff tear, subluxation of the shoulder, recurrent dislocation, subluxation and tear of the biceps tendon, the frozen shoulder, anterior capsular derangements, and combinations of these abnormalities. Arthrography has occasional, but definite use in the wrist, particularly in recurrent ganglion, painful ganglion on the flexor aspect of the wrist, and in the evaluation of the post-traumatic wrist with unexplained pain.

In summary, if the pathophysiology of surgical infection is understood and the principles of treatment are followed, dealing with the complex problems of infected transplants should be less formidable.

Seventeen patients were asked to make a subjective evaluation of their condition after having had a mandibular condylectomy performed. Fourteen of seventeen felt that the surgical procedure had cured their symptoms of pain and limitation of motion. Surgical procedures on the temporomandibular joint are valid when there is organic disease of the temporomandibular joint. However, care must be taken to differentiate between organic disease and the so-called myofascial pain dysfunction syndrome, since surgery is considered inappropriate for the myofascial pain dysfunction syndrome. Even in cases of organic joint disease, care must be taken to identify any existing emotional problems that the patient may have. In cases of organic joint disease with strong psychological overtones, surgical intervention alone may not be enough to relieve the patients of their temporomandibular joint symptoms.

In a study of the duration of antibiotic prophylaxis in elective surgery, 466 procedures were surveyed over a four-year period. It is difficult to prove the efficacy of antibiotic prophylaxis when the rate of infection is so low, and, although not statistically significant, there is no difference in the infection rate whether the antibiotics are given intraoperatively only or for 48 hours, three days, or seven days. Per 100,000 patients, the cost savings of giving antibiotics intraoperatively rather than for 48 hours would have been $7,700,000; with the reduction from seven days to one-dose antibiotics, the savings would have been $29,700,000.

The continuing attempts to reduce bacterial contamination through clean air systems have been of special interest to surgeons dealing in joint replacement surgery. Although the definitive relationship between airborne contamination and surgical infections is not universally agreed on, there is little question that clean air systems reduce bacterial contamination of the surgical wound at the time of operation. This report reviews the history of surgical infections, presents statistical data that show the reduction of bacterial contamination by a clear air system, and suggests a pragmatic attitude regarding airborne bacterial contamination of surgical wounds.

This is a case report of a Cloutier total knee arthroplasty that was removed from an obese, large, 66-year-old man three years after implantation because of aseptic loosening. At surgery there was a thickened black synovium and black cystic areas in the exposed bone. The articulating surfaces of the tibial component, which is made from Poly Two (a carbon polyethylene composite), were grossly abraded, and the supporting metal tray was broken in two. The femoral component showed signs of abnormal wear at the places where it was articulating with the displaced tibial component. The tissues showed a granulomatous reaction with marrow fibrosis and cystic destruction of bone. It is postulated that aseptic loosening was accelerated by a granulomatous response to overload, abrasion, and local dissemination of particles.

Deliberate hypotension was produced during general anesthesia by the infusion of sodium nitroprusside in 13 patients undergoing total hip replacement. Hemodynamic data from these patients were compared with those obtained from 5 patients under normotensive anesthesia for the same procedure. During the hypotensive period, which averaged 1.5 hours, the cardiac index rose 20 percent compared with controls. No acidotic tendency was seen. Blood loss in the study group averaged 475 ml, compared with 1475 ml in controls. From these data, a dose-response curve was derived which may allow the accurate prediction of the minute dosage of sodium nitroprusside required to safely induce hypotension during anesthesia.

The ideal thickness of cement between the prosthesis and bone has not been accurately determined, but there is general agreement that the surgeon should be able to provide and accurately produce a certain thickness of cement between the prosthesis and the bone. Conventional cementing technique could allow the surgeon to ovepush the cup into direct contact with the bone producing a very thin cement coat or a void. We have developed a simple method of achieving a predictable thickness. We insert small spacers made of methylmethacrylate, which can be placed between the bone of the acetabulum and the acetabular component, preventing voids or thin areas in the cement coat. The device has been used in over 50 patients and has proven to be a simple and reliable method of allowing the surgeon to produce a predictable thickness of cement surrounding a joint replacement component. An additional benefit obtained from the use of these spacers is the ability to rigidly hold the acetabular component during polymerization of the acrylic without fear of overpushing. This allows better packing of the bone cement and prevents imperfections caused by the cup contacting the bone.

A case is reported about a patient who was originally treated for bilateral retinoblastoma and subsequently developed an embryonal rhabdomyosarcoma in the masseter. Such patients have a genetic predisposition to a second malignancy that statistically far exceeds the rate for the general population. In addition, current treatment methods also increase the patient's susceptibility to another malignancy. This case emphasizes the necessity of maintaining a high degree of clinical suspicion in the evaluation of any lesion that may appear subsequent to the treatment of cancer in children, particularly bilateral retinoblastoma.

Children with gastrostomies may return to oral feedings provided the health problem which led to its placement has resolved, stabilized, or been corrected. However, attempts to accomplish this are likely to be met with resistance from the child, including gagging, choking, biting, and vomiting. Aspiration and even fatal airway obstruction are possible. Seventeen children with gastrostomies were evaluated to determine appropriateness for oral feedings. Only 10 of this group were deemed acceptable candidates. Five were managed successfully as outpatients and four as inpatients. One patient with dysphagia aspirated, and oral feedings were discontinued. Selection criteria and management methods are described.

Methods of treating fibrosarcoma are difficult to assess because of the slow growth and relative infrequency of the tumor and individual variability. Longitudinal amputation, a method of complete origin to insertion compartmental excision of a soft tissue fibrosarcoma, is presented along with a discussion of indications, contraindications, and surgical technique.

Using the total hip replacement patient, we measured the level of antibiotic in the wound at the time of surgery, the wound drainage for 36 to 48 hours after surgery and over a 10 day period in incubated surgical debris obtained at the time of total hip replacement. The antibiotics sodium oxacillin, lincomycin hydrochloride and sodium cephalothin were administered in standard doses at 6 hour intervals. In one group of patients the antibiotic was begun at the time of surgery, in a second group the antibiotic was begun 24 hours after the completion of surgery. Sodium oxacillin, lincomycin hydrochloride and sodium cephalothin produce antibiotic levels in the venous serum consistently above the level obtained in the simultaneous would drainage specimens. Sodium oxacillin and lincomycin hydrochloride used as described in this study are capable of bathing the area of the surgical wound with concentrations of antibiotics above the minimal inhibitory concentrations. This is evidenced by the antibiotic levels above minimal inhibitory concentrations found in the wound drainage. Sodium cephalothin levels in the wound drainage were below measurable levels in 3 of 4 patients. Sodium oxacillin and lincomycin hydrochloride antibiotic levels in the surgical wound debris and simultaneous venous clotted specimens diminished progressively in a similiar manner indicating no additional effects of the surgical wound debris on the antibiotic's biologic effectiveness. Sodium cephalothin dropped below measurable levels in three days. Measurable levels of antibiotics appeared in the wound aspirate well above the minimal inhibitory concentration in patients receiving their initial dose of sodium oxacillin 24 hours after surgery.

The difficulties involved in quantitating passive cutaneous anaphylaxis led us to examine the rat paw as a site for passive anaphylaxis and to define optimum conditions for passive paw anaphylaxis. Generation of homocytotropic antibodies in a number of different rat strains revealed that female Brown Norway rats were excellent producers of high titre antisera after only a single injection of antigen and Bordetella pertussis. Injection of ratpaws with diluted antisera followed by short (1-2 h) or long (72 h or more) sensitization periods showed that maximum paw swelling occurred 15 min after antigen challenge. Retention of tissue sensitizing capacity in the paw for greater than 35 days but loss of this capacity following heating of antiserum at 56 degrees C, indicated that the rat homocytotropic antibodies involved in passive paw anaphylaxis belong to the IgE class. Experiments using mepyramine, methysergide and diethylcarbamazine showed that 5-hydroxytryptamine is the most important mediator of passive paw anaphylaxis after both a short (2 h) and a long (72 h) sensitization procedure. Passive paw anaphylaxis in the rat is at least as easy to perform as passive cutaneous anaphylaxis, results can be obtained more rapidly and accurate measurement of paw thickness is not difficult. The procedure is a viable alternative to passive cutaneous anaphylaxis and may offer advantages over the latter method especially in the search for, and rapid assessment of, anti-allergic compounds.

Costochondral grafting in growing children for missing, diseased, or ankylosed condyles has been widely reported. The use of these grafts for temporomandibular joint (TMJ) reconstruction in nongrowing adults has received relatively little attention. This article reviews the use of costochondral grafts in six cases of posttraumatic TMJ dysfunction in adults. Four patients increased their maximum incisal opening by an average of 49.1%, and two patients showed decreases in opening. Overall clinical results were judged to be very good. It is emphasized that biologic reconstruction of the adult TMJ is preferable to alloplastic reconstruction because, just as in the growing child, the adult articulation must adapt to the demands of the functional matrix.