International Symposium on bone vascularization

Clinical rheumatology, 1982, 1, N ~ 4, 305-336

International Symposium on Bone Vascularization

Toulouse September 1982

At the third International Symposium on bone vascularization held at Toulouse, France, on 23- 25 September 1982, the following abstracts were submitted.

The Structural Relationship of Bone Forming and Endothelial cells of the Bone Marrow. R. Burkhardt */**, R. Bartl */**, B. Frisch***, K. J~iger*, G. Mahl**, W. Hill**, G. Kettner*.

Previous concepts of not only functional but also genetical connections between all bone forming cells have been challenged by the more recent experimental evidence of a separate stromal respec- tively haematopoietic origin of osteoblasts and osteoclasts. Therefore the reconciliation of these facts with the structural composition of a bone forming unit constitutes an important task of modern histomorphology. Methods: Osseous remodelling has been studied in semithin sections of biopsies of the iliac crest, embedded in methacrylate without decalcification, using five different staining techniques. Semiquantitative,evaluation of the paratrabecular bone marrow areas in all, quantitative comparison of the angio- and osteopenic activities in part of the cases: 160 normal persons, 830 patients with primary osteoporosis, 380 with primary hy- perparathyroidism, 780 with secundary hyperpar- athyroidism, 210 with Paget's disease, 970 with osteomyelosclerosis, 850 with plasmacytoma, 1100 with metastatic carcinoma, and selected cases of tumours of the osteogenic tissues. Results: 1) Increased osseous remodelling bears similar

features in all groups, including the simultaneous involvement of osteoblasts and -clasts.

2) Increased osteoblastic activity is accompanied by increase of the paratrabecular sinusoidal capillaries and vice versa, the endothelia of

which are likely to be transformed immediately into pre-osteoblasts.

3) PAS-staining reveals close functional relations between the sinusoidal capillaries and osteoblasts: PAS-positive material is deposit- ed only in those endothelial cells which are situated opposite of the osteoblastic seams pro- ducing similarly staining droplets.

4) Strong increase of osteoblasts and -clasts coincides with the formation of a loose net-

work of undifferentiated mesenchymal cells, fibroblasts, macrophages, and capillaries, around of the osseous trabecles.

5) This mesenchymal activity is frequently com- bined with the appearance of mast ceils, lym- phocytes, and plasma cells.

6) Immature osteoclasts are to be observed mainly in some distance of the trabecular surfaces, frequently in the position of adventitial cells. They differ from neighbouring macrophages by their lack of siderin granula.

7) Mitotic activity of osteoblasts, -clasts, endothelial ceils and fibroblasts is not uncommon in the activated mesenchymal area.

8) A close correlation exists between angiogene- sis and osteogenesis on one hand, of angiogen- esis and infiltration with the cellular elements of inflammation on the other, in the region of mesenchymal activation.

These observations are discussed in the light of the new theories on the origin of the bone cells.

* Abt. f. Knochenmarksdiagnostik an der Med. Klinik Innenstadt d. Universit~it Miinchen, FRG. ** Abt. f. H[imatomorphologie am Inst. f. H~imatolo- gie, Gesellschaft f. Strahlen- und Urnweltforschung mbH, Miinchen/FRG. *** Inst. of Haematology Tel Aviv Medical Center and the Sackler School of Medicine, Tel Aviv University, Israel.

306 Clinical rheumatology, 1982, 1, N ~ 4,

Etude anatomique de la microvascularisation du p6ron6 et correlations debimetriques. F. Bonnel, J. Teissier, Y. Allieu, A. Cazelas - Unit6 de Re- cherches Inserm U 103 - 8 av. Pr. Grasset - 34000 Montpellier - France.

Les transferts osseux libres revascularis6s par mi- croanastomoses sont maintenant largement utili- s6s dans la reconstruction des pertes de substan- ces osseuses 6tendues des membres apr~s traumatisme ou 6x6r~se tumorale ; plus r6cemment, cette technique a 6t6 appliqu6e aux tentatives de revascularisation des ost6on6croses. C'est le transfert du p6ron6 libre qui est alors utilis6. Les modules exp6rimentaux destin6s h appr6cier le comportement biologique de ces greffes osseuses libres vascularis6es ont pratiquement toujours utilis6 la c6te (doi, weiland). Le but de notre travail est d'envisager un module exp6rimental cor- respondant au p6ron6 trbs utilis6 comme transfert libre en clinique. Nous avons 6tudi6 la microvascularisation et les valeurs d6bim6triques physiologiques du p6ron6 sur une s&ie de 30 lapins blancs New Zealand adultes : - la microvascularisation est 6tudi6e, d'une part apr~s injections de m61ange micropaque minium g61atine suivies de dissections sous microscope et coupes histologiques et d'autre part, aprbs injections de r6sines permettant de r6aliser une corro- sion, on obtient ainsi une syst6matisation de la vascularisation centrale et p6riost6e. - l'6tude d6bim6trique a utilis6 la technique des microsph~res marqu6es (spheres de 15/~ marquees au c6rium 141). Le d6bit moyen global sur le p6- ron6 de lapin est de 6,9 ml/mn/100 g (variance 2,8 - 6cart type 1,7) concernant la r6partition d6- bim6trique, le flux 6piphysaire est trois fois plus 61ev6 que le flux diaphysaire. Enfin, dans le cadre des applications cliniques, nous avons 6tudi6 la microdistribution art6rielle du p6ron6 chez l'homrhe g propos de 29 pi~ces anatomiques inject6es. Dans le cadre des applications cliniques, cette 6tude a port6 sur l'analyse d'art6riographie (55 cas) et la micro-dissection de 29 pi6ces anatomiques inject6es par un m61ange de g61atine micropaque. Sur chaque pi6ce, la dissection de l'6piphyse sup6rieure et de la diaphyse est men6e prudemment avec des contr61es radio- graphiques permettant d'appr6cier la micro-vascularisation. La vascularisation de la diaphyse est sous la d6- pendance des branches de l'art~re p6roni~re qui se disposent en trois groupes de collat6rales mus-

culo-p6riost6es post6ro-externes, post6ro-internes et une collat6rale diaphysaire nourrici~re.

Vascular pattern of the cortical bone as revealed by scanning electron microscopy. Farkas T., Zimmermann I., Siko P., Viola T. National Insti- tute of Traumatology, Baross u 23-25, 1430 Bu- dapest VIII, Hungary.

On fresh human metacarpal bones with application of bending and rotational forces transverse and spiral fractures were performed. This way internal structures of the bone became exposed. Scanning electron microscopy of the resulted surfaces reveals the three dimensional arrangement of vessels in the cortical bone. A network formed by the Haversian and Volkmanns canals is well demonstrated. This pattern is consistent with previous descriptions based on different methods.

Chemical and Enzymatic changes in the chondro- cytes (next to vascular invasion) during endochondral ossification. D. Robles Marin, R. Bros- eta, J.L. Berlanga, M. Aranda, M. Marti, P. An- dreu. Department Anatomy Prof. Smith- Agreda, Valencia, Espana.

After having used various staining technics such as Gomori's, P.A.S., Ramon w Cajal's, Von Kos- sa's, etc.., we arrived at the following conclusions : 1 ~ The protoplasmic secretions that contain blue granules as evidenced by Gomori's technic, will coalesce to from fundamental substance of the nucleus of ossification. 2 ~ ) The precipitation of the calcium salts within the fundamental substance of the ossification centers occurs after the protoplasmatic of the chondrocyte. This precipitation being due to changes in the pH, metabolism. So this precipitation is not the cause of the degeneration. 3 ~ ) The vascular invasion occurs only after the chondral degeneration, and so the secretion is stimulated by chemical trophism. 4 ~ ) The fragmentation and color change of the chondrocitic nuclei coincide with the vascular invasion and because of the similarity of its staining with that of a rat blood cell, the presence of acid phosphatases; all these things pointing out to identical metabolic changes within the chondrocyte as occurs in the red blood cell. In

Clinical rheumatology, 1982, 1, N ~ 4, 307

short the nucleus changes from an alkaline pH to an acid pH. 5 ~ The chondrocyte nucleus has suffered two changes: chemical: an increase of acid phosphatase alkaline phosphatase ratio. Metabolic: an oxidation that is deemed necessary for the final catabolic desintegration.

Femoral Head blood flow in long-term steroid treatment (Study of rabbit model). Gwo-Jaw Wang, S.L. Hubbard, S.I. Regor, E.D. Miller and W.G. Stamp. University of Virginia Medical Center, Charlottesville, VA 22908, USA.

Using a rabbit model, our experiment has shown cortisone-induced hyperlipidemia with subsequent fat embolization of the subchondral vessels. There is also evidence of hypertrophy of the marrow fat cells leading to elevation of femoral head pressure from the normal level of 25 cm. to nearly 60 cm. of water after 8 weeks of treatment. This has led us to believe that pressure changes further decrease blood flow in the femoral head. Materials w Methods: 20 New Zealand white adult rabbits, weighing an average of 4,0 kg., were used. 14 received a weekly dose of 12.45 mg. of Depo-Medrol (Methylprednisone) and 6 served as control. Femoral head blood flow was established using radioactive microsphere technique. Control and cortisone-treated rabbits received a measurement of femoral head flow from 6 and 8 weeks. Results: The average blood flow in the control femoral heads averaged 0.265 + 0.092 cc/ min/gm with no difference in the left side and the right side. In the treated group, the average blood flow at 6 weeks was 0.193 + 0.039cc/ min/gm on the right and 0.267-L-_ 0.047cc/ min/gm on the left which was significantly different at the P ( 0.1 level of confidence. At 8 weeks of treatment, the blood flow was 0.142 + 0.097 cc/min/gm on the right and 0.220 + 0.194 cc/min/gm on the left. This is parallel to unpred- ictable clinical findings in humans.

Cortisone-induced intrafemoral head pressure changes and its response to lipid clearing agents. G.J. Wang, G.J. Rawles, S.L. Hubbard, and W.G. Stamp. University of Virginia Medical Center, Charlottesville, VA 22908, USA.

Long-term cortisone treatment leads to increase of fat cell volume and increase of intrafemoral

head pressure of nearly 30 cm. of water. Clofi- brate has shown effect of modifying serum cho- lesterol and lessening the fat cell size. The experiment is designed to study intrafemoral head pressure with prolonged cortisone treatment and the response to lipid clearing agents. Materials w Methods: 24 New Zealand white adult rabbits were treated with 12.45 mg. of Depo- Medrol weekly. 8 rabbits (Group A) were given 500 mg. of clofibrate at the beginning of the experiment. The other 8 (Group B) had clofibrate 4 weeks after initial treatment of cortisone. 8 rabbits served as control (Group C). Measurement of intrafemoral head pressure was obtained every other week. Results: Group C showed gradual increase of intrafemoral head pressure to 60 cm. of water after 10 weeks of treatment. Group A revealed no change of the intrafemoral head pressure ranging from 20 + 3 cm. of water. Group B revealed initial increase of femoral head pressure at 45 cm. of water at 4 weeks with subsequent gradual decrease of pressure at 15 cm. of water at 14 weeks after clofibrate treatment. The findings indicate that lipid clearing agents will improve intrafemoral head pressure and enhance microcirculation.

Les stades pr~coces des lesions meduilaires et tra- beculaires osseuses induites par la corticoth~- rapie: r~suitats des protocoles exp~rimentaux dans deux esp~ces animales (lapin et pore). PaolaggiJ.B., Le ParcJ .M. , DurigonM., Bar- res D., Paolaggi F. Travail du service de Rhuma- tologie Pr. L. Auquier et du |aboratoire d'Anato- mie pathologie Pr. J. Mignot, H6pital Ambroise Par~, 92100 - Boulogne, France.

L'observation clinique d~taill6e de transplant6s r6naux et ult6rieurement atteints d'ost6on6crose aseptique cortisonique nous a conduit ~ formuler l'hypoth~se que la date de constitution de celle-ci pouvait ~tre pr6coce. Pour l'6prouver, un protocole exp6rimental a 6t6 mis en oeuvre dans deux esp~ces. L'administration de doses 61ev6es de corticoi'des (m6thylprednisone) par vole parent6rale pendant une dur6e de 10 jours a permis les observations suivantes : 1) Chez le lapin: a) un pic d'hyperlip6mie observ6 au 7~me jour, b) une st6atose h6patique et r6nale, c) des embolies graisseuses intra-vasculaires au


niveau de la moelle osseuse. d) En outre, il a 6t6 observ6 une fr6quence tr6s 61ev6e des 16sions m6dullaires de tout stade (I + II + III) d'Arlet et Ficat chez les animaux trait6s par rapport aux animaux t6moins, m~me pour les seuls stades II + I I I (p. < 0,001). e) Chez les animaux trait6s par eorticoides une franche hypofixation de la transcyeline a 6t6 ob- serv6e.

2) Chez le porc nain et le p o r c c o m m u n : a) Aucune variation significative du taux des lipi- des sanguins n'6tait observ6e b) Chez le pore nain, des lesnons medullaires de stade I et II sont observ6es plus fr6quemment chez les animaux trait6s (6 fois sur 11) par rapport aux animaux t6moins (1 fois sur 8) N.S. e) Chez le pore commun, aucune 16sion m6dullai- re ou trab6eulaire n ' a pu &re mise en 6vidence. Apr6s double marquage ~t la t6tracyeline, la mesur des espaees moyens montre une diminution dans le groupe des animaux trait6s (m = 3,5 pm) (t6moins (m = 5/~m)). Ces r6sultats font donc apparaltre une diff6rence de r6ponse pr6eoce aux corticoides suivant les es- p6ces. On peut aussi remarquer qu'il y a une cor- r61ation frappante entre hyperlip6mie et fr6quen- ce des 16sions m6dullaires ce qui tendrait /l ap- puyer l'hypoth6se du r61e possible d'embolies (?) graisseuses dans la pathog6nie de I 'O.N.A. Enfin la pr6cocit6 des modifications m6dullaires est confirm6e dans l 'une des esp/~ces. L'application/L la pathologie humaine n6cessite d'autres explora- tions confirmatives toutefois.

Perturbations du metabol isme de la vitamine D au cours des corticoth6rapies prolong6es. Etude exp6rimentale. F. Blotman, C. Colette, L. Mon- nier, P. Baldet, F. Bonnel, L. Simon. Clinique de Rheumatologie et Clinique des Maladies M6tabo- liques et Endocriniennes. C.H.U. 34059 Montpel- lier Cedex, France.

Afin de pr6ciser le m6canisme des alt6rations osseuses des corticoth6rapies prolong6es, nous avons 6tudi6 chez le lapin, les effets des corticoides (m&hylprednisone 10 mg hebdomadaire, 3 semaines) sur le m&abolisme de la vitamine D. Les taux plasmatiques de 25 hydroxyvitamine D (25 (OH) D) et la fixation osseuse du Calcium 45 (Fix Ca) ont 6t6 tout d 'abord mesur6s chez 18 lapins (groupe I), 7 t6moins (LT) et 11 trait6s par m6thylprednisone (LC). Dans un deuxi6me grou-

pe (groupe II) de 15 lapins, (7 cortison6s, LC, et 8 t6moins, LT) sont mesur~s apr~s injection intra- p6riton6ale de vitamine D C TM et de 25 (OH) D-H 3 les taux plasmatiques de vitamine D, 25 (OH) D et 24-25 dihydroxyvitamine D (24,25 (OH) D) marqu6es, 2 et 6 jours apr6s l 'injection des pro- duits marqu6s. Dans le groupe I, la cale6mie est inchang6e chez les LT et LC. Les taux plasmatiques de 25 (OH) D diminuent signifieativement chez les LC par rapport aux LT. Le volume trab6eulaire osseux baisse significativement chez les LC, en corr61a- tion avec le taux de vitamine D. Dans le groupe II, il persiste plus de vitamine C n4 chez les lapins cortison6s. La 25 (OH) D-H a est diminu6e chez les lapins cortison6s par rapport aux t6moins apr6s l 'injeetion de 25 (OH) D-H 3. Le rapport 25 (OH) D-CI4/ vitamine D-C 14 est plus bas chez les lapins cortison6s que chez les t6moins. La diminution du taux plasmatique de 25 (OH) D ehez les lapins eortison6s est due soit / tune perturbation du cycle ent6roh6patique, soit /tune baisse de la 25 hydroxylation h6patique. De plus, la relation observ6e entre la baisse du volume trab6culaire osseux et la baisse du taux de 25 (OH) D plasmatique semble indiquer que les alt6- rations du m6tabolisme de la vitamine D ont un r61e dans l'ost6oporose des corticoides.

Mesure des d~bits sanguins osseux chez des animaux soumis/t une corticoth6rapie au long cours. G. Bouteiller**, J. Arlet*, A. Blasco, F. Vigoni, A. Eleft&ion.

Si l'ost6on6crose (ON) est une maladie isch6mi- que, il est int6ressant de rechercher si une cortico- th6rapie peut induire chez l 'animal sinon une ON, au moins une diminution du d6bit sanguin osseux. L'exp6rimentation porte sur 15 jars t6- moins et 15 autres trait6s par b6tam&hasone 1 mg/j /animal pendant 5 mois et par m6thyl-pred- nisolone,/l raison de 3 charges de 120 mg/j pendant 3 jours, h 3 reprises. Poids, h6matocrite, cr6atinine, triglye&ides, cholest6rol ont 6t6 con- trol6s toutes les 5 semaines environ. Les d6bits osseux ont 6t6 mesur6s par la m6thode des microsph&es radioactives. Les f6murs sont coup6s en 4 segments : t~te f6morale (A), trochanter (B), diaphyse (C), condyle (D), et leur radioactivit6 est mesur6e pour calculer les d6bits. Enfin, les t~tes f6morales sont pr6par6es pour examen histologique. Rdsul ta ts: Parmi les 616ments biologiques consi- d6r6s, seule la cholest6rol6mie du groupe trait6 se


modifie, avec une ascension tr~s nette (2 fois la normale), juste apr~s les charges de m&hylpred- nisolone. I1 n 'a pas 6t6 vu de foyer de n6crose significatif dans les t&es f6morales. Les d6bits moyens en ml/mn/100g sont les suivants: A = 29,47, B = 25,81 , C = 20,63 , D = 29,07 pour les trait6s. Conclusion : Chez l'oie, les corticost6roides, loin de diminuer les d6bits osseux, tendraient plutot/~ les augmenter. Ces r6sultats seraient alors en ac- cord avec les travaux de Glimcher et Kenzora (1), puis de Kawai et coil (2) qui pensent que l'isch6- mie n'est pas la cause premi&e et fondamentale de I'ON non traumatique. Toutefois, d'autres ex- plications (technique, esp6ce) peuvent aussi ~tre avanc6es pour expliquer ces r6sultats.

* Laboratoire de Recherche ost6o-articulaire, (2HU Rangueil, 31054 Toulouse (France), Centre Hospitalier G6n6ral, route de Tarbes, 32011 Auch, France.

REFERENCES

1. Clin. Orthop. 1978, 130, 47-50. 2. Clin. Orthop. 1980, 153, 273-282. Contrat de Recherche libre. INSERM, n~ 1, 1924.

Flux sangnin 6piphysaire chez ie porcelet normal et apr~s n6crose exp6rimentale de la t~te f6mora- le. A. Trias, L. T6ot et L. T6treault. C.H.U.S., Sherbrooke, Qu6bec, Canada.

La m&hode des microsph~res marqu6es au stron- tium 85 a 6t6 utilis6e par les auteurs pour 6tudier les valeurs normales des flux sanguins sectoriels des os en croissance et les modifications de ces valeurs apr~s cr6ation d 'une n6crose 6piphysaire exp6rimentale chez le porcelet. L'os spongieux 6piphysaire,.m&aphysaire, le cortex et la m6dulla ont 6t6 6tudi6s sur les os longs des membres et le bassin. Matdriel et m~thodes: Sur 16 porcelets f~g6s de 6 semaines a 6t6 exp6rimentalement cr66e une n6- crose 6piphysaire de la t~te f6morale par injection de cire fondue et ligature des vaisseaux 6piphysai- res. Les animaux ont 6t6 suivis post-op&ative- ment de 48 heures h !0 mois apr~s la premi6re chirurgie. Avant sacrifice une injection intra-ven- triculaire de 10 millions ~t 100 millions de microsph~res carbonis6es (3M) marqu6es par du St 85 (400 KeV) 6tait pratiqu6e sous contr61e de pression sanguine et 6cran fluoroscopique. L'organe de r6f6rence 6tait constitu6 par une seringue auto-

matique reli6e ~t un cath6ter aortique. Le pr61~ve- ment &ait simultan6 /L l'injection. Les pi~ces 6taient imm6diatement pr61ev6es (6 sites par os, 8 os 6tudi6s) et radioisotopiquement grace h u n compteur gamma Spectron Picker 500. L'analyse statistique des r6sultats des comptages a 6t6 faite selon la technique de l'analyse de variance apr~s transformation logarithmique des r6sultats (analyse ~ 2 dimensions : variation entre les cochon- nets et variation entre les sites osseux). L'analyse de variance a 6t6 r6alis6e par un plan organis6 en blocs casualis6s. Rdsultats: I1 n'existe pas de diff6rence significative entre les flux sanguins m&aphysaires et 6pi- physaires. I1 n'existe pas de diff&ence marqu6e entre les c6t6s droit et gauche. Le cortex pr6sente toujours des valeurs tr6s inf6rieures ~ la m6dulla. I1 existe des diff6rences significatives entre les membres sup6rieurs et inf6rieurs. I1 existe un gradient entre les os proximaux et les os les plus dis- taux d 'un m~me membre et non une proportion- nalit6 des d6bits h la fertilit6 de l'6piphyse. Bien que cette 6rude soit sans ant6c6dent sur ce type d'animal la validit6 de la technique peut &re prouv6e. Les chiffres sectoriels obtenus sont comparables h ceux de la litt6rature concernant les flux sanguins des os chez l 'animal immature (20 ml/mm/100 g 6piphyse). La comparaison entre l'6piphyse exp6rimentale- ment n6cros~e et le c6t6 sain a montr6 des diff6- rences pouvant atteindre 40 %. Avec la technique d'induction de n6crose 6piphy- saire utilis6e il semble qu'aprbs une 6tape courte de d6vascularisation de la totalit6 de la t~te f6mo- rale, la revascularisation se produit rapidement, sauf dans la petite partie de l'6piphyse off Ies tra- b6cules osseux ont 6t6 d6truits. Cette h6t6rog6n6i- t6 structurale peut expliquer les r6sultats et en particulier l'absence de quantification possible de la revascularisation de la t~te f6morale apr~s n6- crose.

The effect of exposure to compressed air on bone marrow blood f low and its relationship to caisson disease of bone. J. Pooley and D.N. Walder, University Deparment of Surgery, Royal Victoria Infirmary, Newcastle upon. Tyne, England.

The lesions of Caisson disease of bone, which occur in men whose working environments are maintained at a pressure greater than atmospheric, are confined to the major long bones and are considered to be ischaemic in origin. It is accep-


ted, therefore, that hyperbaric exposure can impair long bone circulation, but the mechanism involved remains in doubt. Caisson disease of bone has been found to occur rarely in men who have been subjected to hyperbaric exposures of less than four hours duration. This finding was investigated. Adult rabbits were exposed to compressed air at 28 psi (2 ATA) for periods of four hours or lon- ger. Bone marrow blood flow was studied in one femur using a 133Xe depot clearance technique before, during and after each exposure. With each animal acting as its own control a decrease in 133Xe clearance was demonstrated to occur after four hours at pressure and then for up to one hour following return to atmospheric pressure. This suggested that a decrease in bone marrow blood flow had occurred during and for some time after the exposures to compressed air. A similar investigation, using the technique of osseous phlebography to study bone marrow circulation, provided supporting evidence. No change in skeletal muscle blood flow detected in these animals on similar exposures to compressed air. It was felt that the explanation might be found by considering the microanatomy of the marrow of a long bone. It was postulated that if an increase in volume of the fat cells occurred within the rig- id confines of the marrow cavity as a result of long exposures to compressed air this would account for the observed circulatory impairment, To test this hypotheses, suspensions of isolated fat cells were prepared from rat epididymal fat pad and exposed to compressed air at pressures ranging from 28-90 psi (2-6 ATA). The volume distribution curves of these fat cell suspensions were obtained using a Coulter Counter and Channelizer and compared with those of control suspensions maintained at atmospheric pressure. An increase in fat cell volume resulting from exposure to compressed air was demonstrated. Fur- ther experiments identified a raised partial pressure of oxygen as the causal agent. The addition of a non-diffusible anion (Albumin 2 070 w.v.) to the suspending medium was found to prevent this increase in fat cell volume indicating that it was probably due to depression of the ion pumping system situated within the cell membrane. These results suggest that the toxic action of oxygen inducing a pathological swelling of the fat ceils confined within the bone marrow cavity may be the mechanism responsible for the bone ischaemia in Caisson disease.

Un nouveau module experimental simple d'ost~o- n~crose de la t~te f6morale. P. Griss, M. Mohr, Y. Ishida Orthop/idische Klinik Lindenhof, Fa- kultgt fiir Klinische Medizin Mannheim der Uni- versit/it Heidelberg Meerfeldstr. 69, D-6800 Mannheim:l Fed. Rep. Germany.

Les auteurs rapportent leurs exp6riences avec un nouveau module experimental de production faci- le d'une ost6on6crose de la t~te f6morale dans le chien. La technique operatoire comporte une os- teotomie du grand trochanter passager, une cap- sulotomie lat6rale et une excavation de la t~te f6- morale plus ou moins importante avec une fraise sph6rique sous controle de vue. De telle mani~re il est possible de produire une lesion d'extension d6sid6rable. Dans la cavit6 produite dans la technique d6crite, de l'os spongieux, pris de la crete iliaque du m~me c6t6 par une petite incision sup- pl6mentaire est introduit. Avant que l'os spongieux minc6 est greff6, il est submerg6 dans une solution de formaldehyde de 6 070 pour 45 minutes. Apr~s lavage de l'os pr6par6 de telle mani~re dans saline physiologique pour quelques minutes, l'os n6crotique est pr~t pour remplir la cavit6 dans la t~te f6morale. L'intervention est conclus par une ost6osynthese du grand trochanter. Nous avons produit dans cette technique dix osteon6- croses de la t&e f6morale dans 5 chiens (species Foxhound). La radiologie, morphologie et histoi- re naturelle d'une telle lesion resemblant beaucoup a une osteonecrose idiopatique seront de- montr6es.

Etude scintigraphique des algodystrophies refle- xes et des ost~on~croses de i'adulte. A. Gaucher, A. Bertrand, P. Wiederkehr, C. Hocquard, P. Raul J. Adolphe. Clinique Rhumatologique et Service de M6decine Nucl6aire, CHU de Nancy- Brabois, F 54500 Vandeeuvre, France.

L'exploration scintigraphique des algodystrophies r6flexes (A.R.) et des ost6on6croses (O.N.) de l'adulte ne se limite pas fl l'analyse de la fixation osseuse. Elle comprend aussi l'6tude du flux isotopique et du pool sanguin r6gional. La scintigraphie osseuse (S.O.) classique, compo- s6e d'images statiques retard6es, doit ~tre pr6c6- d6e, d6s l'injection du 99m Tc-MDP, par la prise de vues prbcoces, fl vis6e vasculaire, avec enregis- trement de l'activit6 apparaissant sur des zones d'int6r~t pr6d6termin6es. L'apport des images osseuses est essentiellement diagnostique, celui des images pr6coces surtout physiopathologique.

Clinical rheumatology, 1982, 1, N~ 4, 311

La S.O. refl6te avant tout l'affinit6 de l'os pour les complexes phosphat6s, c'est-h-dire le degr6 de l'ost6oblastose. Les A.R. se traduisent habituellement par une fixation locor6gionale tr6s 61ev6e qui appara~t trbs t6t dans l'6volution de la maladie. Les O.N. se distinguent nettement des A.R. Dans les jours qui suivent la constitution anatomique de la n6crose, il existe une hypofixation pure. Cette hypofixation, traduction directe de la n6crose est progressivement masqu6e par une hy- perfixation p6ril~sionnelle doe ~ une ost6og6n~se r6actionnelle. La zone hypofixante reste cependant souvent visible en cas d 'O.N, de la t~te f6morale, en particulier pour les n6croses massives. Les scintigraphies dynamiques pr6coces montrent que les A.R. en phase active s'accompagnent g6- n6ralement d'une augmentation .du flux isotopique et du pool sanguin r6gional, t6moignant d'une stase, allant de pair avec une activit6 p6ri- articulaire accrue qui correspond h l'oed6me. En ce qui concerne les O.N. il existe une diminution significative du flux sanguin du c6t6 malade par rapport du c6t6 sain. Cette analyse exige que les comptages soient effectu6s sur des zones tr6s limi- t6es, correctement centr6es sur l'os atteint et sur l'os sain contrelat6ral. L'int6r~t physiophathologique des 6tudes dynamiques pr6coces se double pour les A.R. d 'un in- t6r& th6rapeutique : appr6ciation, voire pr~vision de l'effet d'une m6dication donn6e.

The use of rotating slant hole tomography in avascular necrosis of the femoral head. D. Mess, D. Pavel, R. Barmada, University of Illinois College of Medicine. Department of Orthopaedics, 840 South Wood Street, Chicago, Illinois 60612, U.S.A.

The use of Rotating Slant Hole Collimator was used to overcome superimposition of bony structures seen on routine (planar) bone scanning. This was performed on normal hips and those with various orthopaedic problems. All patients were given twenty millicuries of Technetium 99 diphosphonate and imaged 3 hours later. Both routine and tomographic images were obtained for comparaison. A 25 ~ rotating lant hole collimator was rotated into 6 positions 60 ~ apart over each hip. Twelve equal slices of about 1 cm each were processed with a computer. In normal hips there is a homogenous uptake in the femoral head and acetabulum with good

outline of bone and joint space. In all 17 patients with avascular necrosis (AVN) of the femoral head there was markedly increased uptake in the femoral head. When planar and RSHT images were compared 11 of 17 patients with AVN showed a much clear- er picture with RSHT. In these cases a characteristic cold area was seen near the articular surface with a surrounding crescent of increased uptake. Ir~ 3 patients femoral heads removed at the time of total hip arthroplasty were sectioned in the co- ronal plane. This was compared to the corresponding image generated by RSHT. Areas of bony collapse or articular erosion appeared as increased uptake. Cystic areas or intact necrotic areas had a "co ld" appearance on the scan. Even in those cases where Rotating Slant Hole Tomo- graphy offered no advantages over routine bone scans, the definition of bony structures was re- markable. In particular, patients with AVN showed a superomedial cold area with surrounding crescent of increased uptake. I t is felt this is an avascular area surrounded by reactive bone formation.

La captation de col loides par la moel le osseuse comme indice dn d~bit sanguin osseux. F. Schuind 1, A. Schoutens, W. Verhas, A. Ver- schaeren 2. Service de Chirurgie Osseuse 1 et de Diagnostic par Radioisotopes Cliniques Universi- taires de Bruxelles, H6pitaux Erasme et Brug- mann Bruxelles, Belgium.

Cette exp6rimentation sur le rat vise h pr6ciser la relation entre d6bit sanguin osseux et captation par la moelle de colloides.

Materiel et mdthodes: Trois types de colloides sont utilis6s : le m61ange de fluoride de sodium et d'6tain (Amerscan R), des agr6gats colloidaux d'albumine humaine (Solco-Albu-Res g) ou de l 'or colloidal. Ces colloides sont inject6s par voie IV 60 minutes avant le sacrifice de l'animal. Le d6bit sanguin osseux est mesur6 par la m6thode de l'injection de microsph~res marqu6es (3M, diam~tres 15 microM) dans le ventricule gauche et du flux de r6f6rence. La radioactivit6 des f6- murs, des tibias et du sang (flux de r6f6rence) est mesur6e pour les colloides et les microsph6res. On d6termine ainsi la captation des colloides par l'os ou fragment d'os ( % de la dose inject6e) et le d6bit sanguin osseux (microlitres/minute). Trois sch6mas exp6rimentaux sont suivis :


- rats mfiles de 55/~ 150 jours : durant cette p&io- de de croissance, le flux sanguin osseux augmente consid6rablement ;

- rats femelles de 120 jours : modification du d6- bit sanguin osseux par infusion intraveineuse ou intra-art6rielle de drogues vasoactives (nor- adr6naline, ac~tylcholine, gangliopl6giques) ;

- rats femelles de 120 jours : modification du d6- bit sanguin osseux par modification de la tem- p6rature des pattes.

R~sultats : 1) Chez les animaux en croissance, relation li-

n6aire entre la captation de colloides et le d6- bit sanguin osseux;

2) chez l 'animal soumis h des drogues vasoactives, m~me type de relation;

3) chez ranimal soumis/~ des modifications loca- les de temp6rature accroissement moins important de la captation de colloides que celui du d6bit sanguin osseux.

Discussion: Chez le rat, une relation tr6s significative existe entre captation de collo'ides par la moelle osseuse et d6bit sanguin osseux. Toute- fois, plusieurs facteurs influencent cette relation : nature du stimulant vasculaire (froid et chaud), drogues antiinflammatoires (indom&hacine), nature de la pathologie m6tabolique chronique.

Etude microcirculatoire de t~tes f~morales n~cro- s~es ~t raide de microsph~res radio-actives. J.P. Steib, G. Lang, B. Moysses, K. Kleinklaus, Hopi- tal orthop6dique St6phanie - 67026 Strasbourg - France.

L'art6riographie supra-s61ective de l'art~re circonflexe post6rieure traduit mal l'&at de la vascularisation de la t&e f6morale notamment n6- cros6e. Une obstruction de l'artbre circonflexe post&ieure n'est pas synonyme de n6crose et une art~re circonflexe post&ieure normale n'indique en rien l'6tat vasculaire de la t&e f6morale. C'est pourquoi nous pr6sentons une s6rie de cas o/~ la vascularisation de la t~te f6morale est mise en 6vidence par l'injection de microsph~res r6sor- babies de s&um-albumine dans l'art~re circonflexe post6rieure. Une 6tude pr61iminaire sur l'animal et sur des t~tes f6morales chirurgicales, nous a encourag6 /~ r6aliser cet examen dans le bilan des ost6on6croses ou comme moyen de d6pistage. En effet, cette fagon de proc6der donne une car- tographie art6rielle de la microcirculation de la t~te f6morale et d~limite les r6gions non-vascula- ris6es. Cette scintigraphie osseuse art6rielle prou-

ve l'obstruction art6riolaire sans indiquer sa nature primitive ou secondaire et met en 6vidence certains m6chanismes de compensation vasculaire intra-c6phalique. I1 s'agit surtout d 'une m6thode

valeur exp6rimentale h titre de recherche mais elle pourrait ~tre d6velopp6e comme moyen de d6pistage pr~cose.

Circulation et micro-circulation. Ph~nom~nes d'interf~rence sur la micro-circulation par la m~- thode d'~tude scintigrapho-informatique. M. Ram - Permanence de Cornavin - 1256 Gen~ve (Suisse).

L'objectif de ce travail est de pr6senter le r6sum6 des travaux r6alis6s jusqu'h pr6sent h l'H6pital Cantonal de Gen~ve et la mise en 6vidence des possibilit~s d'utilisation de la m6decine nucl6aire, compl6t6e par des recherches de math6matique dans l'&ude de la micro-circulation ainsi que leur application pratique. Matdriel de mdthode: Des examens ont 6t6 r6alis6s chez des patients atteints de maladie os- t6o-articulaires compar6s aux examens d'autres organes. Des 6tudes avant et apr~s traitement st6- ro~dien ont 6galement 6t6 faites. I1 a &6 utilis6 une gamma-cam6ra coupl6e h l 'or- dinateur avec possibilit6 d'6tude math6matique. Des mesures de perfusion osseuse sont r6alis6es approximativement chez mille patients et des 6tu- des plus approfondies sont r6alis6es chez une partie des cas au moyen d 'un transfert/t un ordina- teur plus puissant. R~sultats: L'6tude math6matique des taux de comptage sur les zones d'int6r& nous a permis de mettre en 6vidence des ph6nom~nes p6riodiques longs d'environ 1/2 h 2,5 minutes que nous appe- Ions "pulsations" et des ph6nom~nes rapides d'une fr6ctuence de moins d'une/seconde jusqu'h 25/secondes que nous appelons "vibrations". Nous avons pu remarquer que: 1) Les pulsations correspondront ~ la micro-cir-

culation. 2) La Cortisone, dans les premiers r6sultats obte-

nus, r6duit la longueur de la p~riode des pulsations et par ce moyen le volume de la micro- circulation.

3) Les vibrations peuvent interf6rer et supprimer, pendant leur apparition, les pulsations dans un endroit d6termin&

4) Les valeurs de la pulsation, dans son passage par un tissu n6crotique, changent.

5) Les interf6rences, par les vibrations endog~nes


ou exog~nes, peuvent se manifester sous forme d'algies ischdmiques.

6) I1 existe la possibilit6 d'influencer ces interfd- rences par l'utilisation de mddicaments.

L'art6riographie s61ective dans les n6croses de la t~te f6morale. Exp6rience de 5 ans. J. Theron, CHU, Caen, France.

L'art6riographie supers61ective de la hanche est habitueUement rdalis6e par cath6tdrisme supersd- lectif de l'art~re circonflexe postdrieure. 1) Dans les n6croses primitives, l'image est con- stitude par une hypervascularisation entourant la zone n6crotique avasculaire. Cet aspect peut ~tre retrouv6 prdcocement. L'interruption des art~res capsulaires correspond aux limites de la zone ndcrotique. Des ldsions vasculaires peuvent &re observdes sur la hanche con- trelat6rale asymptomatique ~t une necrose ; la non apparition d'une n6crose correspond ~t une revascularisation pr6coce. Un phdnom~ne positionnel peut 8tre retrouv6 avec interruption de l'art~re circonflexe post6rieure en extension et rdopacification en fexion. La S6paration ne doit pas ~tre trop stricte entre coxarthrose et ndcrose. Des ldsions vasculaires peuvent &re retrouvdes dans des ldsions dvocatri- ces de coxarthrose en radiologie standard. La situation de la t~te f6morale par rapport au fond du cotyle a une relation avec le balancement de la vascularisation entre art~res capsulaires supdrieu- reset inf6rieures. 2) Dans les ldsions traumatiques, l'artdriographie permet au ddbut d'affirmer qu'une ndcrose ne surviendra pas si la t~te est bien vascularisde, par contre la 16sion des art~res capsulaires peut ~tre compensde par la suite par le ddveloppement im- pr6visible d'une circulation collatdrale. Dans les pseudarthroses, la connaissance de la vascularisation de la tSte permet un meilleur choix thdrapeutique en fonction de l'~ge du malade.

La thermom~trie dynamique de la rotule. M. Collette. Service orthop6die, Clin. Univ. St Luc- 1200 Bruxelles (Belgique)

I1 s'agit d'une m6thode thermomdtrique destinde appr6cier qualitativement le ddbit sanguin intra-

rotulien.

Principe: si l 'on refroidit momentandment la rotule, elle tente de retrouver sa tempdrature initiale d~s que le refroidissement a cessd. La vitesse de r6chauffement ddpend en principe du ddbit sanguin des tissus sous-jacents. Si l 'on supprime la circulation des tissus mous prd-rotuliens, le processus de rdchauffement ddpendra surtout des phdnom6nes circulatoires intra - osseux. Technique: les deux genoux du patient reposant sur une attelle, on applique une thermistance sur la face antdrieure de la rotule et les tissus mous prd-rotuliens 6tant ischdmids par un bandeau de caoutchouc auquel on suspend deux poids de 3 kgs. Apr6s un refroidissement de 2 minutes rdalis6 par contact avec de la glace fondante, on enregistre le processus de r6chauffement pendant 10 h 12 minutes. Les courbes de deux genoux sont ensuite analysdes puis compardes entre elles du point de vue de la rapiditd du processus de rdchauffement. Application: Nous avons tout d'abord r6alisd cette technique chez 35 sujets jeunes et en bonne sant6, servant de population tdmoin. Darts ce groupe, la vitesse de r6chauffement des deux rotules n'est jamais fortement asym6trique. Ayant ensuite examind 41 patients prdsentant un syndrome f6moro-patellaire, nous avons pu, par comparaison avec le groupe normal tdmoin, mettre en dvidence parmi 12 malades, une diffdrence de la vitesse de rdchauffement des deux rotules statisti- quement significative. Les anomalies thermomd- triques observdes peuvent ~tre soit une augmentation soit une diminution de la vitesse de rdchauffement par rapport au c6t6 sain. Ces anomalies semblent bien ~tre d'origine circulatoire: on peut en effet les reproduire expdri- mentalement soit en diminuant le d6bit sanguin au moyen d 'un garrot placd h la racine du membre soit en l 'augmentant par effort physique important. En comparant entre eux les malades positifs et ndgatifs h la thermomdtrie, on trouve par- miles positifs une majoritd de cas posttraumatiques. Ces patients se plaignent le plus souvent d 'un seul c6td et leurs rotules sont pour la plupart radiologiquement centrdes. Ces dldments sere- blent donc cadrer parfaitement avec l'hypoth6se de l'origine traumatique des troubles ddcelds. Songeant tt la possibilitd d'une stase sanguine intra-rotulienne, nous avons rdalis6 chez quelques patients des perforations extra-articulaires de la rotule dans le plan frontal avec des r6sultats parfois spectaculaires sur la douleur.


La vascularisation osseuse dans l'~volution des fractures - P. Ficat, R. Durroux, E. Horvath, M. Boussaton, J.N. Senie. Clinique Chirurgicale Or- thop~dique et Traumatologique, Centre Hospita- lier Universitaire de Toulouse - Rangueil - Fran- ce.

Toute solution de continuit6 osseuse est aussi une solution de continuit6 vasculaire qui int6resse tout ou partie de la circulation osseuse. Si les 6ta- pes histologiques d u c a l osseux sont bien connues, celles de la r6paration vasculaire le sont beaucoup moins c'est ce dernier point que nous avons voulu pr6ciser. Matdriel et M~thodes : Cette &ude est bas~e : 1 ~ sur un travail exper imental : 20 cas de fractures et 20 cas de pseudarthroses chez le lapin 6tudi6s ~t l'aide d'ost6om6dullographies puis d'examens ra- diographiques et anatomo-pathologiques coupl6s apr6s micro-angiographies du syst6me art6riel se- Ion la m6thode de trueta et 2 ~ un travail cli-

nique bas6 sur les ost6om6dullographies, la prise de pression intra-m6dullaire et l'6tude anatomopathologique de cas de pseudarthroses en microscopie optique et 61ectronique. Les r6sultats se di- visent en deux groupes : fractures et pseudarthroses .

A~ Celui des Fractures - Nous a permis de d6cri- re le d6roulement de l'6volution vasculaire intraosseuse en trois 6tapes : a / u n s tade initial d'h6- matome inter-fragmentaire; b. un stade secondaire de proli fdration cellulo-vasculaire avec or- ganisation d'un cal m6dullo-p6riost6 de nature fibreuse ou fibro-chondrale et plus tard osseuse. Mais/t ce stade 1/l il n'y a toujours pas de corn% munication circulatoire entre les deux fragments sup6rieur et inf6rieur ; c / en f in un troisibme stade de r6unification vasculaire r6tablissant une circulation centro-m6dullaire fonctionnelle aussi bien art6rielle que veineuse. Tousles fairs observ6s nous autorisent /~ penser que le r~tablissement de la continuit6 vasculaire non seulement pr6c~de mais m~me d6clenche le processus de consolidation osseuse. B/Ce lu i des Pseudarthroses - Inversement l'absence de r&ablissement vasculaire ira de pair avec une pseudarthrose. Nous avons propos6 une clas- sification anatomo-pathologique en pseudarthrose hypertrophique, dystrophique et atrophique; bien que diff6rentes sur le plan morphologique, toutes ces vari6t6s se caract~risent par une absence de communication vasculaire fonctionnelle entre les deux fragments avec isch6mie du tissu d'in- terposition fibreuse.

Conclusion - Cette r6unification vasculaire centro-m6dullaire des deux fragments en pr6sence nous parait constituer un fait fondamental dans le processus de consolidation osseuse.

Nylon Cerclage: The bone circulation in experimental osteotomy. M. Brookes and F.W. Heatley. Department of Anatomy, Guy's Hospi- tal, London SE1 9RT.

The aim of this investigation was to compare natural bone healing with repair in the presence of cerclage bands; either flat or Partridge's nylon bands which are elevated above the bone surface by small bumps in the bands. A standard femoral incomplete oblique osteotomy was cut in 15 greyhounds. One group served as controls ; in the second group, the osteotomy was cerclaged with 3 flat nylon bands; and in the third group with Partridge bands. The dogs were examined angio- graphically and histologically up to 12 weeks post-operatively. The results show that bone healing occurred in all 3 groups. Histological damage, dead tissue, osteoporosis, empty lacunae and curtailment of periosteal callus occurred severely in bone repair with flat bands. Cerclaged bone is more hyperva- scular than in natural repair. But in control and Partridge osteotomies, the cortex does not show abnormal patterns of vascularisation as found with flat cerclage, because the periosteal surface is not obstructed. In particular, Patridge's nylon bands cause minimal interference with the blood supply to healing bone.

Nylon Cerclage: principles and clinical applications. F.W. Heatley and M. Brookes. Depart- ment of Orthopaedic Surgery, St. Thomas' Hos- pitaI, London SE1 7EH England.

Cerclage with wide nylon bands was originally pioneered by S.J. Partridge for the treatment of femoral shaft fractures distal to a femoral hip im- plant, and was later extended to the treatment of femoral fractures occurring in elderly and osteoporotic patients in combination with intramedullary rods. As a method of internal fixation of fractures in long bones, cerclage has been criticis- ed in the past on both biological and mechanical grounds. In our view, nylon cerclage causes less disturbance to the bone circulation than either plates or intramedullary nails. Cerclage fails for


mechanical reasons. Although it gives excellent fracture reduction, this cannot be maintained against angulation forces ; nor can cerclage act as a bridge across the fracture site and restore the geodesic properties of a tubular bone. Hence cerclage should never be used as the sole means of fixation but in combination with intramedullary rods or plates, when it can provide an excellent solution to some very difficult fractures. Ex- amples of its use will be shown and discussed.

tive. These 5 were not subjected to electrostimu- lation ; they healed subsequently. Conclusions: When stress x-rays prove inconclu- sive, venography can be useful. It is most reliable when positive; when negative, non-union is not necessarily indicated.

REFERENCE

1. Puranen and Kaski: J. Bone joint Surg., 56A;759, 1974.

Clinical and experimental use of intraosseous venography to assess fracture non-union. J.F. Connoily, D. Chakkalakal, and M. Kelbel, Uni- versity of Nebraska Medical Center and Veterans Administration Medical Center, Omaha, Nebras- ka, U.S.A.

Intraosseous venography for assessing fracture healing, although used clinically, has not yet been validated by animal studies. Lack of demon- stration of venous flow through or around the fracture gap by twelve weeks has been considered to be indicative of non-union (1). In this study, we have evaluated the use of venograms of osteo- tomized and intact canine radii by a fourpoint bending test of these radii. We have also used venography to evaluate 20 patients referred for electrical stimulation of ununited fractures. Animal Studies: (A) 17 adult dogs were subjected to transverse osteotomy of the radius (B) para- film was inserted between the fragments in four of these. Intraosseous venograms were obtained every third week. Between 5 and 10 weeks the dogs were sacrificied and mechanical strength of experimental versus control radius was determined by a four-point bending test. Prefracture venogram demonstrated the intramedullary venous network with proximal drainage. In the immediate post-fracture venogram, venous network was not visualized proximal to the osteotomy. In (A), there was proximal visualization by 8 to 10 weeks associated with mechanical strength of experimental radius exceeding 50 % of control. In (B), there was proximal visualization, although somewhat less; but mechanical strength never exceeded 14 ~ This indicated that either venography is of no predictive value or the pseudoarthrosis model (B) in inadequate. Clinical Studies: Intraosseous venography was done in 20 patients in conjunction with stress x- rays. Venograms and stress x-rays demonstrated some healing in 3 patients ; in 2 others, the venogram was negative but the stress x-rays were posi-

Vascularity and cortical remodelling after intramedullary nailing. (Experimental findings on the tibia of the sheep) Pfister U., Tubingen, Fed. Rep. Germany.

In addition to the damage caused by the fracture itself internal fixation may lead to a further irri- tation of cortical blood flow. After plate osteosynthesis the peripherial bone underneath the plate is avascular to a certain extent. This avascular area is revascularized by vessels ingrowing from the regularly vascularized surrounding cortex. The hereby resulting remodelling is inducing a marked porosis. The blood flow of the cortex is centrifugally like under normal physiological conditions. Unlike to this situation after intramedullary nailing the avascular area is localized at the inner side of the cortex. The revascularisation takes part by extending haversion vessels and big resorption lacunae. The remodelling seems to be supported by vessels from the periosteal parts of the cortex and it progresses in a centripetal di- rection. Our findings after intramedullary nailing allow to suppose that the periosteal system is able to take over the blood supply of big parts of the cortex in case of a destroyed medullar system. On the other hand, it seems to be possible that the so called "porosis due to stress protection" is at least partially the expression of a revascularisation process after disturbance of cortical blood flow caused by the osteosynthesis.

Early scintigraphy of tibial shaft fractures - prognostic value ? P.J. Gregg, C.B. Clayton, G.K. Ions and S.R. Smith. University Depart- ments of Orthopaedics and Medical Physics, Royal Victoria Infirmary, Newcastle upon Tyne, England, U.K.

Ischaemia of bone adjacent to fractures of the tibial shaft may be an important factor in their


subsequent healing. An attempt has been made to study this by scintigraphic examination soon after injury on the assumption that tracer uptake would only occur in the presence of an adequate blood supply and therefore regions of impaired blood supply would appear as 'cold-spots' on the scintigraph. Forty six patients (mean age + SD = 34 + 17) with forty eight fractures of the tibial shaft were examined using methylene diphosphonate labelled with technetium-99 m, and a gamma camera fitted with a high sensitivity parallel-hole collimator. Thirty six fractures were closed and twelve were open; only three were treated by primary internal fixation. Forty one fractures were examined within one week of injury of which ten were examined within twenty four hours. Scintigraphs were obtained of the fractur- ed and contralateral (control) tibiae and analysed visually for the distribution and intensity of rad- ioactivity concentration." In all cases there was a generalised increase in tracer uptake in the frac- tured tibia, even in those imaged within twenty four hours of injury; in twenty four cases there was an additional local increase of tracer uptake in relation to the fracture. In six tibiae (12%) 'cold-spots' were observed, however two of these united within twenty weeks. Fourteen fractures (29 o70) were not united twenty weeks after injury, among which all types of tracer uptake pattern were observed. In conclusion, ischaemia of bone adjacent to a tibial shaft fracture (as indicated by this technique) seems to be uncommon and the appearance of a single early scintigraph would appear to be of little prognostic value as regards subsequent union.

Thermic osteonecrosis after drilling in the cortical bone . H. Schmelzeisen, S.M. Perren, B. Rahn. Unfallchir. Klinik, D 7630 Lahr, Fed. Rep. Ger- many.

After drilling with different drills (sharp drills of different types, used drills) the increase of temperature has been measured in a defined distance from the edge of the drill-hole. In simultanous tests the zone of reduced blood-supply around the drill-holes have been proved by in vivo stainings: disulfine blue, polychrome sequence- marking. The results show, that unfavourable drill-conditions may create zones of defective blood supply, which extend firmly the depth of the thread of usual corticalis screws. Through experimental and clinical examination it is known,

that there exists the possibility of screws loosen- ing in such damaged areas. The remodelling results from the non-damaged areas from periostal and endostal vessels asowell as from the region of cortical anastomoses. The medullary circulation system ist especially important since it is not only responsible for a part of the remodelling but also an additional temperature drainage because of its vessel-architecture in spite of the higher temperature at the drill's head at the end of drilling action in comparison to the beginning. Obviously the drill material has influence to newly bone and to the drill canal.

A comparison between microangiography and vital microscopy in the evaluation of bone vascularization. T. Albrektsson, Laboratory of Experi- mental Biology, Department of Anatomy, Uni- versity of Gothenburg, Sweden.

Micropaque and India ink perfusions are frequently used trying to delineate the vascular system in experimental studies of bone tissue. Even if well controlled microangiography is performed, it is known that many vessels will not be filled out with the contrast medium. The reason for this poor vascular filling has been suggested to depend on either a contrast medium blockage of capillaries or on the existence of functionally resting vessels in bone tissue. The titanium bone chamber, as described by Alb- rektsson (1979), allows in vivo and in situ studies of bone blood vessels. The true vascular state of an observable bone tissue compartment, including the most minor capillaries, was first determined by vital microscopy. Thereafter, microangio- graphic filling of the same tissue with either Mi- cropaque or India ink was performed under simultaneous inspection of the vascular delineation. The infusions were undertaken at a controlled pressure of 130 mm Hg after administration of Heparin or Xylocain to the animals. The thus obtained microangiograms were compared with the true - as defined by slides and cin6 film recordings - vascular state of the same bone compartment. On the average, less than 50 ~ of the actually functioning vessels were filled out by India ink or Micropaque. Resting vessels were not responsible for the poor vascular delineation. Fixation by freezing and formaldehyde administration was successful as no contrast media-filling was lost during these procedures. Decalcification with for-


mic acid did interfere with the degree of vascular filling in some Micropaque specimens. In conclusion, Micropaque and India ink microangiography provides a static image of the vascular situation in living bone and underesti- mates the true bone vascularity, at least in the rabbit tibial metaphysis. The reason for this poor vascular filling is either a direct capillary blockage or an indirect one, due to intravascular mixing of contrast medium and blood. Albrektsson, T., Healing of Bone Grafts, Thesis, University of Gothenburg, Sweden.

Extraction of 99m Tc methylene diphosphonate as a function of bone blood flow. I.D. McCarthy and S.P.F. Hughes, University Department of Orthopaedic Surgery, Princess Margaret Rose Orthopaedic Hospital, Fairmilehead, Edinburgh, EH10 7ED, Scotland, U.K.

About 20 years ago, Crone and Renkin derived an equation relating capillary permeability (P) surface area available for exchange (S) blood flow (Q), and extraction (E) i.e. PS = -Q In (I- E). We have measured extraction at different flow rates in bone and used this equation to study changes of permeability surface area product with flow. The nutrient artery of the tibia of greyhounds was cannulated, and this was perfused with blood at flow rates of 0.76, 1.9, 3.8, and 7.6ml/min. Extraction of 99m Tc-methylene disphosphonate (MDP) was studied by injecting a bolus of 99m Tc-MDP and 125I - albumin, a vascular tracer, and measuring the relative concentrations of these tracers in the femoral vein over a 2 1/2 minute period after the injection. The maximum in- stantaneous extractions at these four different flows were 0.41 +_ 0.18, 0.42 +__ 0.13, 0.27 + 0.10, and 0.12 +_ 0.035. There was no significant difference between the calculated permeability surface area products at flows of 1.9 mls/min and above. It is suggested that the surface area available for exchange remains constant at these flows and therefore that there is no capillary recruitment as flow increases in response to increased perfusion pressure. The equality of measured extraction at flows of 0.76 and 1.9 mls/min suggests that the assumptions made in deriving the model are not valid in this flow range and that transport approaches flow limitation in this range. The im-

plications of these observations for measurement of extraction in bone will be discussed.

Bone blood flow and extraction ratios: microspheres and bone seekers. P. TothiU and G. Hooper Departments of Medical Physics and Or- thopaedic Surgery, Royal Infirmary, Edinburgh, U.K.

We have previously drawn attention to possible limitations of microspheres as tracers for bone blood flow and extraction ratio measurements (Calcif. Tissue Int. 31, 261, 1980). Our doubts arose from apparent extraction ratios by bone of ISF and 85Sr, based on microsphere uptakes, o f greater than one. More recent experiments have demonstrated that our single-passage measur- ments were invalid, as the transit time through bone is too prolonged for unexchanged tracer to be cleared before recirculation occurs. The extraction ratio for ~8F measured by Wootton (Clin. Sci. Mol. Med., 47, 73, 1974) is also invalid. Although extraction ratios cannot be determined by single-passage experiments, values greater than unity are still not explained by transit time problems. Moreover our recirculation experiments are not appreciably affected. The re- suits of these are in general agreement with the work of Schoutens et al (Am. J. Physiol. 236, HI, 1979) which also demonstrates some ano- malously high extraction ratios for bone seekers at low flow rates. When our results for all bones in the rat are pooled, we, like Schoutens et al, find a reduction of extraction ratio with increase in blood flow. We had speculated that the anomalies might be due to the loss of microspheres in capillaries tra- versed by blood before entering bone. An alternative explanation could be shunting of microspheres (but not bone-seeking tracers) in the bone vasculature. We have shown that in the dog tibia such hunting can occur in some circumstances, but that usually it is negligible.

Bone blood flow in conscious dogs at rest and during exercise. E. Tondevold. M.D. Dept. Or- thop. Surg. Hilleroed Hospital. DK-3400 Hill- erod. Denmark. J. Billow. M.D. Inst. Med. Physiol. C. Univ. of Copenhagen. 2100 Copen- hagen O. Denmark.

Using the microsphere technique bone blood flow was measured in different anatomical and


functional regions in long bones in conscious dogs. The measurements were performed during physical exercice upon a treadmill, and the bone blood flow values were obtained as prework resting values, after 1 and 2 hour exercise and after 1 hour's rest. The perfusion rates increased 50 % from 1.6 to 2.5 ml- 1oo g tissue -1. min ~ in the femoral and tibial cortical bone during work. In the cancellous bone of the femoral head an increase from 12.6 to 20.6 tg/ml- 1oo g tissue -1. min -1 was found Equal flow responses were determined in the fat filled tibialcondylar and femoral supra- condylar bones. The increase took place after 2 hours exercise, but nonstatistical verified increased perfusion was found after 1 hours work. The alternation in bone blood flow suggests that bone has a capability of physical vasodilatation during muscular work, but the flow response is slow and therefor the vasodilatation seems med- iated by a metabolic induced stimulus.

seal metaphysis demonstrated the greatest flow in each bone. The area just beneath this also had relatively low flow. Metaphyseal flow increases centrally. Flow to the tibia was less than flow to the femur. Mature (more than two years) animals demonstrated highest flow in the cancellous portions of the femur, particularly the intertrochanteric region. Cortical flow was limited throughout the adult femur and tibia. The adult tibia receives substantially less flow than the adult femur. Regional osseous bloou L~ow tends to be greatest in regions of highest metabolic activity, usually in association with osteogenesis, osseous remodeling or hematopoiesis.

Circulation sanguine et viabilit~ de la plaque de croissance. P. Vicente et A. Trias. C.H.U.S. Sherbrooke, Qu6bec, Canada.

La viabilit6 du cartilage de conjugaison d6pend de sa couche germinale juxta 6piphysaire et en

Bone blood flow - regional variation with skeletal cons6quence on attribue ~t la circulation 6piphy- maturation. T.R. Light, Loyola University salre un rSle nutritif essentiel ~ sa survie. Une School of Medicine, Maywood, IL, USA M.R. McKinstry, Pittsburg, J. Schnitzer, Pittsburg, J. Ogden, New Haven, CO, U.S.A.

Regional osseous perfusion was quantitated in dogs at three different ages using radioactive microsphere technique. Through a left thoracotomy approach, the left atrial appendage of each animal was exposed and a catheter placed. A carotid catheter was employed to monitor systemic flow. Animals were awakened and injected with 15 mi- cron microspheres through the atrial catheter. A Harvard pump was used to simultaneously with- draw carotid samples at a fixed rate. Animals were sacrificed at five minutes. Kidneys, femurs and tibias were excised and sectioned into as many as 41 subregions. Segmental perfusion (expressed in cc/min/100g was calculated for each region. Neonatal (four day) animals femoral and tibia flow patterns were similar. The evolving physeal region received greater flow than any other neonatal region. Within the cartilaginous epiphysis central flow was higher than peripheral flow. The immature (four month) animals demonstrated greater flow in the peripheral portion of the secondary ossification center than were demonstrated centrally. The immature physis demonstrated limited flow while the adjacent juxtaphy-

isch6mie de l'6piphyse devrait donc alt6rer la .croissance en longueur des os puisqu'elle entrai- nerait une d6g6n6rescence de la plaque de croissance. Or ceci n'est pas la r~gle comme par exemple dans la majorit6 des cas de maladie de Perthes oh le raccourcissement est peu important. Pour 6valuer le rSle de la circulation dans la survie de la plaque 6piphysaire, une suppression s61ective et progressive a 6t6 provoqu6e dans 4 groupes de lapins. Dans tous les cas une d6sarticulation au niveau du genou a 6t6 pratiqu6e, prenant soin de ligaturer les vaisseaux 6piphysaires provenant de l'art~re poplit6e jusqu'au dessus de la plaque 6pi- physaire. Dans un deuxi~me groupe on y ajoute une 16sion par 6videment du condyle lat6ral du f6mur, alors que dans le troisibme groupe on ajoute h la d6sarticulation, la r6section d'une frange circonf6rentielle du p6rioste proximal l'6piphyse f6morale distale. Finalement dans un quatri~me groupe on associe la d6sarticulation l'6videment du condyle externe et h la r6section p6riost6e. Les r6sultats d6montrent que dans tous les groupes l'isch6mie de l'6piphyse est totale au d6but et qu'h long terme toutes les 6piphyses sont bien revascularis6es. Dans tousles groupes aussi on observe des 16sions pr6coces de la plaque 6pi- physaire mais dans les groupes I e t II il n 'y a pas eu r6section de la frange p6riost6e on ne retrouve pas de 16sions permanentes h long terme et il n 'y


a pas d'alt6ration de la croissance. Quand on ajoute ~t la d6sarticulation une r6section de la frange pdriostde (groupes III en IV) des 16sions pr6coces de la plaque dpiphysaire sont plus graves et plus 6tendues et h long terme il en r6sulte une ddsint6gration complete de la plaque de croissance qui entraine des graves perturbations dans la longueur de l'os. Les conclusions sont que la survie de la plaque 6piphysaire est surtout ddpendan- te de la circulation pdriph6rique de la plaque 6pi- physaire qui elle-m~me est nourrie de vaisseaux pdriph6riques provenant autant du versant meta- physaire qu'6piphysaire. Les 16sions d6gdn6rati- ves de la plaque dpiphysaire, m~me les ponts osseux peuvent se r6soudre dans le temps pourvu que la portion p6riph6rique de la plaque reste viable. Ces r6sultats mettent en doute les assertions sur le r61e de la circulation 6piphysaire en gdn6ral et m~me de la fonction de toute la plaque dpiphysaire dans la croissance des os longs. En effet toute la portion p6riphdrique du cartilage de conjugaison, incluant l'encoche de Ranvier, para~t avoir un r61e prdpond6rant dans la croissance des os en longueur, le restant de la plaque semble avoir surtout un r61e de remplissage pour emp~cher l'dpiphysiod~se. Ceci nous a amend t~ poursuivre l'dtude de la circulation des zones sec- toddles de la plaque mais d 'en dvaluer son r61e dans la croissance des os au lieu de considdrer toute la zone du cartilage de conjugaison comme une zone homog~ne.

Animal model for the study of bone blood supply, osteocyte death and bone remodelling. Gunst M.A., Rahn B.A., Ltithy U. and Perren S.M. Labor fiir experimentelle Chirurgie, Schweizeri- sches Forschungsinstitut, Davos, Schweiz.

Osteocyte death was observed in the cortex of long bones after plating for internal fixation. A complete lack of blood perfusion immediately postoperative may contribute to osteocyte necrosis in these areas. It is likely that venous efflux is obstructed by the plate, thus intensifying the effect of disturbed medullary blood supply. Revascularisation of plated cortices begins at the endosteal medullary surface and proceeds towards the plate. Bone remodelling restores functioning vascular channels to these areas, however along with the remodelling activity goes a marked porosity of the cortex under the plate. The porosity may be a

result of reduced mechanical load on this part of the bone or a consequence of bone necrosis. An animal model for the study of the interdepen- dency of osteocyte death, bone blood supply and bone remodelling will be presented. Pathogenetic mechanisms for osteocyte death in this laboratory model will be discussed.

Fluid spaces in the canine tibia. G. Hooper, I. McCarthy, R. Wootton, S.P.F. Hughes, Univer- sity Department, Princess Margaret Rose Ortho- paedic Hospital, Edinburgh,. EHI0, 7ED, Scot- land, U.K.

We have studied the distribution of various tracers in the cortical bone and marrow of the tibiae of nephrectomised dogs. The equilibration periods and the postulated spaces of the tracers were :- Tracer Time Space 124i.Alburnin l0 minutes Plasma 51c~ Eo'rA 2 hr. 10 minutes Extracellular gg~Tc-red blood ceils 10 minutes Red blood

At the end of the equilibration period the dog was sacrificed, both tibiae removed and counted. Venous blood haematocrit and cortical bone density were measured. We have calculated the volumes of the following spaces (results are Mean 1 +_ S.D. ml/ml):

Cortical Bone Marrow

Plasma 0.0059 • 0.0008 0.019 • 0.006 Intravascular 0.013 • 0.002 0.038 • 0.017 Extravascular 0.102 • 0.058 0.218 • 0.292

Mechanism of ion transfer, especially that of calcium in bone. S.P.F. Hughes and P.J. Kelly, Ed- inburgh University, United Kingdom, and Mayo Clinic, U.S.A.

Bone is a complex structure which, in addition to its function as a structural framework, has the capacity to grow and remodel in response to stress and also to repair itself by forming new bone. The bone consists of a diffuse capillary vascular lattice, which allows exchange of ions to occur between the bulk extracellular fluid and the bone cells and crystal. In this paper a review will be made of the work initiated and carried out by Dr. Patrick Kelly at


the Mayo Clinic in the understanding of the vascular anatomy of bone, fluid transport and the transport of ions and molecules within bone. Reference will be made to the application of this understanding of the basic physiology of bone, particularly to calcium exchange and also in fracture repair. This paper will take into account recent work undertaken in Dr. Kelly's laboratory at Mayo and our own laboratory in Edingburgh.

The relationship between intraosseous and in- traarlicular pressure. C. Arnoldi, Rigshospitalet, Copenhagen, Denmark.

In painful osteoarthritis the pressure in juxtaarticular bone-marrow is increased and the drainage from the medullary space impaired. The reason for the impaired drainage has long been unknown. In many joints the anatomy indicates that the veins could be compressed by high in- traarticnlar pressure. In order to find out if this mechanism could be responsible for the high intraosseous pressure seen e.g. in human coxarth- rosis and in patients with the intraosseous en- gorgement-pain syndrome, experiments were performed on rabbits and horses. In rabbits the pressures in the knee joint, the juxtaarticular bone- marrow and in an ear artery were measured simultaneously. Injection of saline into the knee was accompanied by an immediate rise of joint pressure, followed by a slower rise of intraosseous pressure. In horses we measured the pressure in the fetlock joint and in the metacarpal bone-marrow. A rise of joint pressure was followed by a rise of bone-marrow pressure, as in rabbits. Further, flexion of the joint above 60 degrees was accompanied by a significant rise in intraosseous pressure. These results are best explained by a blockage of intraarticular drainage veins with intact arterial inflow to the bone-marrow. The clinical significance of these findings are discussed.

Regional blood flow and intraosseous pressure changes of the juvenile knee in experimental arthritis. C. Bringer. Orthopedic Hospital and Insti- tute of Experimental Clinical Research, Universi- ty of Aarhus, DK 8200, Denmark.

In order to elucidate pathogenetic factors of growth disturbances and degenerative bone

changes in juvenile arthritis the influence of synovial inflammation and intra-articular pressure on the hemodynamics of the juxta-articular bones was investigated in an experimental model. Unilateral arthritis was induced by weekly instil- lation of Carragheenin solution into the knee joint of 26 mongrel puppies for 3 months. After bilateral implantation of Tantalum markers in the femoral diaphyses the growth patterns of the knees were followed by a standardized X-ray technique during induction of arthritis. Thereaf- ter simultaneous intra-articular and intraosseous pressure measurements were performed during control conditions and various degrees of knee joint tamponade in 12 dogs. In 14 dogs the relationship between regional blood flow rates (RBF) and intra-articular pressure of the knee were determined by tracer microsphere technique. Four flow measurements were performed in each dog. The experimental juvenile arthritis resulted in epiphyseal overgrowth and osteoporosis of the knee with decreased endochondral and appo- sitional bone formation of the distal metaphyseal femur. The intraosseous pressure of the distal femoral epiphysis and the intra-articular pressure was significantly elevated, while the intraosseous pressure of the distal femoral metaphysis and proximal tibial epiphysis was unchanged. A 3 - 4 fold increase of RBF of the knee joint capsule and menisci was observed in the arthritic knees along with a 1 - 2 fold increase of RBF of the juxta-articular metaphyses, while the RBF of pat- ella and juxta-articular epiphyses was largely unchanged. The intraosseous pressure response and RBF changes during increasing intra-articular pressure demonstrated an augmented circulatory vulnerability of distal femoral epiphysis and knee joint capsule of the arthritic knees. The results demonstrate the significance of intra- articular pressure elevation in relation to the hemodynamics of the juxta-articular bones of arthritic knees. The subsequent metabolic and vascular changes may be of major importance in the pathogenesis of the growth disturbances observed.

Effect of diaphyseal injury on the proximal growth zone of the tibia in rabbits. Kery L., Bu- dapest Karolina ut 27, II13 - Hungary.

In growing chinchilla rabbits, the effect of various diaphyseal injuries - cortical drilling and


closed fracture - on the epiphysis, the growth plate and the metaphysis of the tibia was studied radiographically, histologically and with the aid of 51 Cr labelled erythrocytes. It was found that the disturbed circulation, the venous stasis may have a marked effect on osteogenesis and bone growth.

In the early stage after the injury widening of the zone of germinative and proliferative cells in the growth plate and a reticular arrangement of the bony trabeculae in the epiphysis and metaphysis were observed. In the late stage, along with a return to normal circulation, normalization of the osteogenesis and bone growth was also found.

Effect of calcitonin, hydrocortisone and para- thyroid hormone on canine blood vessels. M.F. Driessens, G. Mortier, P.M. Vanhoutte: Akad- emisch Ziekenhuis Antwerpen, 2520 Edegem - Belgium.

Experiments were designed to determine whether or not calcitonin parathormone and glucocor- ticoids have direct effects on the vascular smooth muscle cells of bone blood vessels. Tibias of mongrel dogs were isolated: the arteria nutriens was cannulated and perfused at constant flow with aerated Krebs-Ringer solution (37~ The perfusion pressure was continuously recorded. In unstimulated preparations calcitonin caused dose-dependent increases in perfusion pressure, indicating that it causes constriction of bone blood vessels. Parathormone did not affect basal perfusion; it did not significantly alter vasocon- strictions caused by the injection of norepineph- fine indicating that the hormone has no direct effect on the vascular smooth muscle of bone blood vessels. Hydrocortisone, at low concentrations, augmented the constrictions caused by exogenous norepinephrine and periarterial nerve stimulation; at higher concentrations, hydrocortisone caused a dose-dependent inhibition of the response to adrenergic activation. The depressant effect of hydrocortisone was antagonized by pro- pranolol, suggesting that the glucocorticoid facil- itates beta-adrenergic relaxation of the vascular smooth muscle cells by catecholamines. The vasoactive properties of calcitonin can explain part of the effect of this hormone in Pa- get's disease and reflex sympathetic osteodystro-

phy, by reducing the pathologic augmentation of bone blood volume.

Effets des cat6cholamines sur la iipolyse de la moEIle osseuse du tibia de chien. M.A. Tran, Dang Tran Lac, M. Berlan. Laboratoire de Phar- macologie M6dicale, Facult6 de M6decine, 37, All6es Jules Guesde - 31000 Toulouse - France.

Le r61e physiologique du tissu adipeux de la mo~lle osseuse n'est pas bien 6tabli. L'hypoth~se, g6n~ralement admise, sugg~re que la moElle adipeuse de l'os constitue un tissu de structure, non mobilisable (1). A l'oppos6, le contenu lipidique de l'os joint un r61e m6tabolique et participe aux processus h6matopoi6tiquies(2). Enfin, le tissu adipeux de l'os n'intervient pas dans le bilan 6nerg6tique de l'organisme (3). Nous avons 6tudi6 les effets des cat6cholamines st,,r la mo~lle adipeuse tibiale d'une part " in vivo", d'autre part " in vitro". Dans les 6tudes "in vivo" nous avons 1) perfus~ h d6bit constant l 'ar- t~re nourrici~re de l'os par le sang de l'art~re f6- morale homolat6rale; 2) mesur6 le taux des aci- des gras libres (A.G.L.) darts la partie art6rielle aff6rente d'une part, dans la veine nourrici~re d'autre part; 3) inject6 dans le perfusat les cat6- cholamines. Dans les 6tudes " in vitro", nous avons compar6 les capacit6s de mobilisation des A.G.L. de la moElle osseuse ~ celles du tissu adipeux omental. - L'Adr6naline, ~t la dose de 0,025 /~g/min. et

l'Isopr6naline, ~t la dose de 0,025/~g/min. 61~- vent le taux des A.G.L. dans la veine nourrici~- re .

- " In vitro", l'Adr6naline et l'Isopr6naline d6ter- minent une augmentation du taux des A.G.L. beaucoup plus intense dans le tissu omental que dans le tissu adipeux osseux.

En r~sum6 : le tissu adipeux de la mo~lle osseuse est donc mobilisable, mais ses capacit6s de mobilisation sont extr~mement r6duites, compar6es celles du tissu omental. Ces r6sultats sugg~rent que la mo~lle adipeuse de l'os est impliqu6e dans les processus de nutrition locale, plut6t que dans le bilan 6nerg6tique de l'organisme.

REFERENCES

1. Erslev. A.J. 1967. Clin. Orthop6d., 52, 25-36. 2. KrauseR.F. 1943. J. Biol. Chem., 149, 395-404. 3. BathijaA., S. Davis and S.Trubowitz. 1979. Amer. J. of Hematol., 6, 191-198.


Clinical and experimental studies on bone circulation and osteonecrosis following alcohol abuse. S. Solomon, C.M. Schnitzler, H. Seftel, D. Men- delsohn, H. Kundig. University of the Witwaters- rand, Johannesburg, South Africa.

Although an association between alcohol abuse and 'idiopathic' osteonecrosis is well recognised, the pathogenetic link is poorly understood. Con- tending hypotheses favour endarterial fat embolism or else fatty congestion (steatosis) of the marrow causing occlusion of vascular sinusoids. We present the results of 2 parallel studies : (a) a clinical and histomophometric investigation of 45 patients with alcohol-induced bone disease, and (b) and experimental study of bone changes and lipids in alcohol-fed rats. Early changes in alcoho~iic osteonecrosis. 27 patients (mean age 49) with unilateral femoral head necrosis admitted to excessive alcohol intake (more than 150 g/day). In 9 intraosseous pressures were measured on the 'unaffected' side and core biopsies of the femoral head and neck were obtained. Pressures were significantly raised even during this pre-clinical stage and the histology showed widespread fat cell necrosis. Fat cell size in 12 femoral heads with established osteonecrosis was significantly greater than normal and the overall proportion of fatty to myeloid tissue was increased. Alcoholic osteoporosis. 18 patients (mean age 65) with severe osteoporotic fractures gave a history of alcoholism. None had any evidence of osteonecrosis. They were generally older, more debilitated and more osteoporotic than those with bone necrosis. Quantitative histomorphometry and mi- croradiography showed decreased bone formation and increased resorption with no features of osteomalacia. Experimental alcoholism. 36 Sprague-Dawley rats were divided into 3 groups of 12. Group 1 was fed a normal diet and water ad lib. Group 2 was given a daily supplement of 12~ alcohol. Group 3 was fed a normal 'diet plus sucrose to match the calorie intake of Group 2. By 40 weeks about half the animals were still alive. Intraos- seous pressures were measured and then, after sacrifice, bones and liver were retrieved for esti- mation of lipid content and histological examination. In no case were the classical changes of osteonecrosis produced. The 'alcoholic' group showed fatty infiltration of the liver and features resembling alcoholic osteoporosis in humans. In

cases with trabecular fragmentation fat cell size was significantly increased. Conclusions: 1. The clinical studies suggested that 'alcoholic' osteonecrosis is uncommon and occurs in an early phase of alcohol abuse ; longs- tanding debilitated alcoholics develop osteoporosis rather than necrosis. The occurence of marrow ischaemia depends on the anatomical site, bone status and the presence of steatosis. 2. Experimental changes in the rat resemble those of debilitation and osteoporosis rather than classical osteonecrosis ; however, in some there is un- equivocal fatty congestion and increased fat cell size.

The incidence of femoral head necrosis in a population with a known daily intake of ethanol. J.P. Van Vuren, Department of Orthopaedic Sur- gery, Faculty of Medicine, University of Stellen- bosch, Tygerberg, 7505, South Africa.

This paper reports the incidence of femoral head necrosis (FHN) in four hundred and ninety three male subjects. All the subjects received natural white wine as part of their conditions of service. This wine has a constant ethanol content of ten volume per cent. The volume of the daily intake of ethanol was calculated from the daily volume of wine consumed by each individual subject. This was regarded as the minimal daily intake of ethanol because all subjects drank wine over the weekends, but the latter was not included in the data because the author regarded this volume as unreliable. The daily volume of ethanol varied between 35cc to 150cc of ethanol per day. Each subject was subject to an anteroposterior pelvis x-ray examination, including both hip joints tro- chanteric ans subtrochanteric areas. A blood specimen was taken for a liver battery test from each subject. An analysis was made of each subject as regards to frequency of daily ethanol intake, the volume of daily ethanol intake and the periode of time of daily ethanol intake. There were five subjects with symptomatic hips and advanced irreversable x-ray signs of femoral head necrosis (F H N) in the sample of four hundred and ninety three labourers. All five drank methylated spirits (methyl alcohol) over weekends. Sixty Nine x-rays showed small radiolucent areas surrounded by sclerosis in the capital and femoral neck area. It is the author's opinion that these changes are related to femoral head necrosis. Sixty four out of sixty nine of these subjects had abnormal liver function. Three hundred


and eighty six asymptomatic patients with normal x-rays had abnormal liver function tests. In the author's opinion, the daily intake of ethanol in vollames up to 120cc does not appear to play a significant role in the pathogenesis of femoral head necrosis (FHN). A second group of eighteen patients presenting at Tygerberg Hospital with irreversable changes of femoral head necrosis (F H N) have been analysed. It is the author's opinion that in this analysis, a daily intake of ethanol of one hundred and fifty cub centimetres or more ethanol per day appears to be a significant factor in the pathogenesis of femoral head necrosis (FHN) due to ethanol.

Osteonecrosis in the renal transplant recipient - a prospective study. R.K. Spence, M.D., A. Alavi, M.D., C.F. Barker, M.D., R.G. Grossman, M.D., B. Slaven, M.D., M.E. Steinberg, M.D., 3400 Spruce Street, Philadelphia, PA 19104; J. Lane, M.D., Hospital for Special Surgery, 535 E. 70th Street, NY, NY 10021. U.S.A.

Osteonecrosis remains a significant complication of renal transplantation which defies early de- tection. This prospective study was undertaken to determine the diagnostic and prognostic value of the history, laboratory data, x-rays and serial bone scans; and to gain additional information concerning the etiology and pathogenesis of the condition. 74 patients,undergoing renal transplantation were evaluated by history, physical examination, com- prehensive laboratory studies, x-rays and bone scans. Studies were performed at the time of transplantation and at 3, 6, 9, and 12 months. X-rays and scans were also repeated whenever patients developed musculoskeletal symptoms. 16 patients rejected their grafts within 12 months, 18 died, and 4 were lost to follow-up. The remaining 36 completed the study and were then followed routinely from 50 to 76 months. Of this latter group, 5 patients (13 ~ developed osteonecrosis of the femoral head between 4 and 50 months after transplantation (mean : 23 months). The initial diagnosis was made by a positive bone scan after the onset of hip pain. In 2 patients routine x-rays were also positive at this time, whereas in 3 patients x-rays were negative until 3 to 5 months later. There were no positive scans prior to the onset of pain. There was no clear correlation between the development of osteonecrosis and the history, laboratory data, or most other parameters evaluated. There was a relation-

ship to the administration of steroid, but no direct relationship to dose or duration was established. The role of renal osteodystrophy alone appeared less significant. Laboratory studies are of little value in determin- ing which patient will develop osteonecrosis. The bone scan remains perhaps the best early indica- tor, although in this series it did not lead to a diagnosis prior to the onset of pain. A positive scan in a symptomatic hip, even in the face of a normal x-ray, warrants a presumptive diagnosis of osteonecrosis and consideration of early treatment.

L'Ost~on~crose des condyles f~moraux chez le transplant~ r~nal. J. Benoit, H. Danon, A. Lor- tat-Jacob, J.Y. Dupont et M. Durigon. Clinique Chirurgicale Orthop~dique et Traumatologique - H6pital Ambroise PARE - 92100 Boulogne - France.

L'~tude porte sur 27 interventions pour n~crose des condyles f~moraux chez le transplant~ r~nal de 1973 A mars 1982 chez 19 malades (6 bilat~- raux et 2 r~interventions). L'~tge moyen est de 26 ans. Le nombre relativement important de ces interventions t6moigne du handicap entrain~ par les n~croses condyliennes ; pendant la m~me p~riode, les n~croses de la t~te f~morale qui sont defr~- quence plus grande ont n6cessit6 54 interventions; les n~croses de l'astragale et de l'~paule n 'ont n~cessit~ aucune intervention. L'indication chirurgicale au genou est essentiellement port6e devant l'importance des troubles m6caniques (hy- darthroses, blocages, instabilitY) associ~s ~ la douleur. L'ablation simple des corps ~trangers libres est parfois suffisante et sa r~alisation sous arthroscopie associ~e ~ une r~gularisation m~nis- cale ~ventuelle permet maintenant de ce contenter souvent de ce geste simple qui peut ~tre renouvel~ si n~cessaire. Le plus souvent, cependant, l'~tendue de ces l~sions et l 'importance de la destruction osseuse justifient un remodelage condylien par arthrotomie. Chez deux patients, une ost6o- tomie secondaire de valgisation a dfi ~tre prati- qu6e. Aucune proth~se de genou n 'a ~t~ posse chez ces patients A haut risque septique bien que dans la m~me p~riode, les 33 arthroplasties de hanche r~alis6es n'aient entrain6 aucune complication septique. L'examen histologique de l'~piphyse f~morale confirme l'~tendue de la n~crose. L'~volution de ces 6piphyses n~crotiques montre l'absence d'~crasement global des condyles corn- me on pourrait le suspecter en comparaison avec les destructions des t~tes f~morales.


The Incidence of Avascular Bone Necrosis following Renal Transplantation using Radionuclide Bone Scanning. J.D. Spencer, Guy's Hospital. London, U.K.

In the Guy's Hospital Renal Unit a total of fifty two patients received a renal transplant between July 1978 and July 1979. Forty two surviving patients were followed up, for a minimum of two years and a maximum of three years, with six monthly whole body bone scans. The survey was undertaken to determine as accurately as possible the incidence of avascular bone necrosis in our patients, its time of onset, and whether osteonecrotic lesions could be present in the patients but asymptomatic. Seven patients out of the forty two who fell into the range of the survey following renal transplantation developed avascular osteonecrosis. In two of these patients, the osteonecrotic lesions would not have been discovered, if routine bone scanning had not been performed. Despite a fall in steroid dosage in recent years, the survey suggests that the incidence of avascular bone necrosis following renal transplantation remains high, at 17%.

Anatomie des lesions osseuses de la drepanocyto- se. R. Cabannes w F. Sombo Mambo D6pt. D'Immuno-H6matologie CHU BP v166 Abidjan, C6te d'Ivoire.

Parmi les h6moglobinopathies dites communes, la dr6panocytose, due ~ I'HbS, est la plus fr6- quente. Les individus de race noire paient un lourd tribut h cette affection. Des millions d'Afri- cains sont porteurs de l 'anomalie parmi lesquels plusieurs millions pr6sentent ta forme majeure de la maladie. Au cours de celle-ci, les complica- tions, en particulier osseuse sont fr6quentes. Chez le dr6panocytaire, les troubles osseux r6sul- tent de deux ph6nom~nes : 1) Modifications li6es ~ l'h6molyse chronique conduisant h l'hyperplasie compensatrice de la moelle ossense (expansion et hypercellularit6 du tissu m6dullaire). 2) Modifications dues aux troubles h6mato-vasculaires aboutissant h la thrombose, ~ l'isch6mie et ~t la n~crose. Ceux-ci sont li6s en majeure partie

la qualit6 du sang (ph6nom~nes rh6ologiques) qui influ6 sur la circulation intraosseuse provo- quant un ralentissement de la circulation et une stase plus ou moins important selon l'intensit6 de l'hypoxie intraosseuse.

L'exemple de la n6crose aseptique de la t~te f6- morale ou de la t~te hum6rale sont des exempples typiques de l'6volution de l'6tat osseux des 4 dr6- panocytaires. L'6volution anatomopathologique de l'os est 6tudi6e sur cet exemple.

Spontaneous osteonecrosis of the knee. E.T. Ha- bermann, Montefiore Medical Center/Albert Einstein College of Medicine and M.A. Hartz- band. Bronx, N.Y., 10467 USA.

36 patients with spontaneous osteonecrosis of the medial femoral condyle treated at the Montefiore Medical Center/Albert Einstein College of Medi- cine were reviewed. All patients were followed for a minimum of two years. Ages rang~ed from 54 to 84 years with an over-all mean age of 67.

There were 28 females and 8 males.

Two-thirds of the patients had been previously labelled with an incorrect diagnosis, most frequently medial meniscal tear (13 patients) and osteoarthritis (7 patients). Twenty-seven of thirty- six patients denied any history of trauma and ni- neteen noted that the pain was worse at night. The pain was typically unrelieved with rest. Phy- sical examination revealed pain on palpation of the medial femoral condyle in 31/36, patello- femoral crepitus in 9/36, and localized synovial thickening in 3/36. One-third of patients had some mild loss of terminal flexion and/or extension. 11 of 36 patients had a normal x-ray examination at the time of initial presentation. All 36 eventually developed the typical lesion with subchondral lucency and surrounding sclerosis. Technicium 99 labelled pyrophosphate scanning was positive in all knees that were scanned and demonstrated marked, local tracer uptake at the medial femoral condyle. 19 of 36 patients were treated conservatively with analgesics, cane or or- thotic device and an exercise program. Average initial knee rating score in this group was 70 and, at the time of most recent examination was 81. 17 of 36 patients were treated operatively with indications which included intractable pain, angular deformity, gross instability or loose body. Proce- dures included arthrotomy and drilling (4), high tibial osteotomy and arthrotomy (3) and total knee replacement (10). Average initial knee rating score was 64 pre-operatively and 84 postoperatively. Arthrotomy and drilling accounted for the bulk of faire and poor results and is not recom- mended in this study.


L'ost~onecrose idiopathique de la t~te du ler mttatarsien. HI Zollinger, St. Kubik, A. Schreiber, Orthop/idische Universitiit Klinik, Balgrist - 8008 Zurich - Suisse.

La litttrature ne contient que des rapports isolts des alt6rations de la t&e du ler mttatarsien qui sont appeltes osttochondrose disstquante, ost6o- ntcrose ou maladie de K6hler I de la t~te du ler m&atarsien. Vu la ressemblance radiologique de cette osttontcrose avec d'autres formes de ntcro- ses d'articulation sph6riques, nous nous sommes posts la question d 'une analogie ttiopathogtni- que de ces tableaux cliniques. Parmi les patients de la Clinique Universitaire Orthop6dique de Balgrist, nous rapportons 12 cas bien document,s d'osttontcrose primaire de la t~te du ler m6tatarsien avec une anamn6se et des signes cliniques et radiologiques largement con- cordants. Dans 3 cas, il ttait possible d'&udier l'image histologique h la suite du traitement opt- ratoire des troubles articulaires. Des techniques sptcialistes permettent la raise en 6vidence des vaisseaux irrigant la t~te du ler mttatarsien. Les connaissances de l 'anatomie de ces vaisseaux, ainsi que les donntes radiologiques, histologiques et optratoires nous permettent une prise de position quant aux difftrentes hypotheses ttablies sur l 'ttiopathogtn~se de ce tableau clinique encore peu connu et son analogie possible avec la ntcrose idiopathique par exemple de la t&e du f6mur.

Histopathologie des necroses non traumatiques de la t~te femorale. Donn~es topographiques et tvolutives. J. Arlet*, R. Durroux**, Ch. Fau- chier*, Toulouse, France.

I. Ldsions observdes dans la t~te et le col fdmoral au dessous du s~questre. Sur 67 sptcimens prtle- vts par forage-biopsie darts des t~tes ftmorales ntcrostes aux stades radiologiques III ou IV (osttontcrose compliqute avec affaissement, ou "collapse", de la t~te ftmorale), nous avons con- stat6 au dessous du stquestre et de son socle sclt- rost, des ltsions de ntcrose mtdullaire dans 85 % des cas et de n6crose trabtculaire partielle dans 61% des cas. La ntcrose mtdullaire est le plus souvent de type "rtt iculte tosinophile", elle est parfois granuleuse avec dtbris nucltaires lorsque la moelle htmatopoi&ique est interesste, elie peut s'accompagner de formations kystiques ou bul- leuses, parfoi~ bordtes d'histiocytes lipophagi-

ques. Le remodelage trabtculaire (ttudit sur les coupes non dtcalcifites) est peu important. Des ltsions de m~me type et de m~me topogra- phic ttaient retrouvtes 14 fois sur 15 t~tes ftmorales ost6ontcrotiques prtlevtes pour proth~se totale. Ces constatations soulignent le caract6re dif- fus des troubles circulatoires et des ltsions n6cro- tiques darts l 'osttontcrose non traumatique. 2. L~sions prdcoces observdes au stade I (non radiologique) ou II (remaniements architecturaux sans affaissement) de la ntcrose de la t&e ftmorale. Nous les avons t tudit sur 12 forage-biopsies, fait ~t ces stades I ou II, symptomatiques, chez des malades qui prtsentaient une ntcrose compliqute, affaisste (stade III ou IV) de l'autre hanche. Dans ces 12 cas, il s'agissait donc de n6- crose cliniquement tr6s probable (bilattralisation) mais rue prtcoctment. On constatait une ntcrose mtdullaire de la t~te et du col ftmoral dans 9 cas et une ntcrose trabtculaire partielle dans 7 cas. Ces constatations permettent d'affirmer que les premibres 16sions de l 'osttontcrose non traumatique de la t&e ftmorale sont mtdullaires, ttendues et radiologiquement invisible. Elles peuvent &re reconnues par la biopsie et ainsi prtcoctment traittes. 3. Sur 15 t~tes ftmorales pr61evtes pour proth~se totale h la suite d'une ntcrose de la t~te ftmorale compliqute d'affaissement (stade II ou IV) rnais antdrieurement traitdes par forage-biopsie, nous avons t tudit le devenir du canal de forage et con- front6 les ltsions osseuses sur la biopsie et sur la t~te ftmorale enti~re. La gutrison anatomique de la zone biopsite et des rtgions voisines a t t t ob- servte.

* Laboratoire de recherhce ost6oarticulaire du CHU de Rangueil. ** Laboratoire Central d'Anatomie pathologique du CHU de Rangueil, 31054 Toulouse C6dex.

Histo-pathologie de deux t~tes f~morales atteintes de ntcrose primitive (avant ie stade l'effondrement). Pathogenies differentes (ischemie progressive, infarctus aigu). F. Jacqueline, Aix-les- Bains, France et W. Remagen, Institut de Pathol- ogic, Universitt de B~e, Suisse.

Dans la premiere t~te ftmorale, une vaste plage anttro-suptrieure est composte de foyers de fibrose mtdullaire et d'osteoscltrose ~ diverses phases de leur tvolution. De nombreux foyers sont ntcrosts. Certains de ceux-ci sont en grande partie r6sorbts par un tissu angio-fibreux; ~ la


p6riph6rie de ce tissu apparaissent d6j/~ des m6ta- plasies osseuses importantes. Autour de cette vaste plage, se d6veloppe une angio-fibrose mod6r6e. L'6tude de cette piece, au stade de d6but, permet de pr~ciser la pathog6nie des 16sions trbs complexes observ6es habituellement aux stades ult6- rieurs. Elle montre aussi la pr6cocit6 des r6sorp- tions des foyers n6cros6s et des reconstructions osseuses. Cette revitalisation semble ~tre de courte dur6e, car, d6jA, des foyers d'os n6oform6 sont

nouveau n6cros6s. Par contre toute la moiti6 sup6rieure de la seconde t~te f6morale est n6cros6e, sans remaniements tissulaires pr6alables. Ce sequestre est nettement d61imit~ du territoire inf6rieur par une ~troite bande fibro-vasculaire. Ces deux pi~ces illustrent deux pathog6nies diff6- rentes: l'une, habituelle, avec une isch6mie progressive, en foyers confluents; l 'autre, exceptio- nelle, avec une isch~mie totale et brutale attei- gnant d'embl6e tout le territoire sup&ieur.

Documents anatomiques d'ost6on6crose de la t~te f~morale. P. Baldet, F. Bonnel, L. Monnier, J.M. Saint-Andr6 F. Blotman, L. Simon. Clini- que de Rhumatologie et Laboratoire d'Anatomie Pathologique. C.H.U. 34059 Montpellier Cedex. France.

Si les 16sions histopathologiques de l'ost6on6crose de. la t~te f~morale sont bien connues, leurs m6chanismes sont encore fortement discut6s. Les marquages h la t6tracycline du tissu osseux avant forage biopsique ou r6section de la t&e f6morale pour arthroplastie dont des exemples sont pr6s- ent6s, apportent des notions dynamiques int6res- santes. La n6crose des trav6es, qu'il y ait ou non persis- tance des ost6ocytes se traduit par une absence complbte de marquage. La n6crose de la plaque sous-chondrale est pr6coce. Par contre, la mort du cartilage parait beaucoup plus tardive, comme en t6moigne la longue persis- tance d'une activit6 de min6ralisation sur la "tide mark". La r6paration osseuse dans le foyer n6- crotique et la condensation osseuse p6riph6rique s'accompagnent d'une augmentation du nombre des foyers d'opposition sans modification de la vitesse de calcification.

Trouble d'ossification de la t~te f6morale dans ia luxation cong6nitale de la hanche. Vizkelety T., Mester u. 22. 1095 - Budapest - Hungary.

Les deux facteurs d6cisifs au cours du traitement de la luxation cong6nitale de la hanche sont le d6but pr6cose du traitement et la m6thode la moins nocive. Entre 1957 et 1975, nous avons ap- pliqu6 le bandage de Pavlik chez 3156 enfants porteurs d'une dysplasie ou d 'une luxation. Chez la plupart des enfants le traitement fut commenc6 entre l'~ge de un et cinq mois. Chez 76 ~ la gu6- rison fut parfaite mais dans 24 ~ des cas, il fallut continuer le traitement avec une atelle d'abduction. L'ost6ochondrite de la t~te f~morale ne fut observ6e que dans 2 ~ des cas, mais exclusive- ment dans la deuxi~me groupe. A la suite des travaux exp~rimentaux et des analyses des r6sultats des divers traitements, nous pensons que l'ost6ochondrite est provoqu6e par la position prolong6e en abduction. L'abduction cr6e un 6tirement de l'art6re circonflexe post6- rieure. Nous avons observ6 un trouble d'ossification sp6- cial, la bascule en dehors de la t~te f6morale, apr6s traitement orthop6dique mais surtout apr6s ost6otomie de varisation-d6rotation f6morale. L'~tude .~. tologique de la t~te f~morale et du cartilage de conjugaison montrait des caract~res et une distribution des vaisseaux qui expliquent le d6veloppement de l'ost6ochondrite et la bascule en dehors de la t~te f6morale.

Metaphyseal changes in Perthes' disease - a hypo- thesis. S.R. Smith, A.J. Malcolm, P.J. Gregg. University Departments of Orthopaedics and Pa- thology, Royal Victoria Infirmary, Newcastle upon Tyne, England, U.K.

Metaphyseal changes occur frequently in Perthes' disease and seem to affect the prognosis (Ions et al 1981) but their pathogenesis remains unknown. Previous attempts to produce ischaemia of the upper femur have not enabled the metaphysis to be studied in detail as they have involved a direct invasive approach to the hip or used small animals capable of rapid revascularisation. In order to overcome these difficulties sterile glass microspheres (60 urn) were introduced into the right external iliac artery of six immature Gottingen pigs so as to result in embolism of the femur. The femora were examined by radiography and scintigraphy using methylene diphosphonate labelled


with technetium 99m at five and eleven weeks. The animals were killed at sixteen weeks, the femurs excised and examined by radiography and standard histological techniques. Radiological changes were present in the metaphysis of one animal resembling those seen in Perthes' disease and histological examination showed that these changes were related to the presence of an arrested portion of growth plate surrounded by subchondral bone formation within the metaphysis. Immediately above there was a corresponding defect of the growth plate filled with fibroblastic tissue. In the epiphysis there was widespread marrow necrosis and foci of bone death. No such abnormalities were seen in the contralateral femurs and all scintigraphic examinations were negative. This suggests that the epiphyseal ischaemia produces an infarct of a portion of the growth plate which then becomes arrested in the metaphysis as the adjacent, non-infarcted plate con- tinues to grow normally. The arrested cartilage and fibrous tissue result in the radiotranslucency and the subsequent bone deposition for the surrounding sclerosis on the radiograph. These findings support the suggestion that metaphyseal changes are secondary to epiphyseal ischaemia in Perthes' disease. Ions GK, Smith SR, Gregg PJ. The Radiological Features of the Metaphysis in Perthes' Disease. Read at British Orthopaedic Research Society, Liverpool, 1981.

L'Importance des vaisseaux intraosseus dans le processus de gu~rison des ost~omyelites chroni- ques. Warda E., Klinika ortopedii ul Jaczewskie- go 8, 20950 - Lublin - Pologne.

La r6sistance des germes pathog6nes aux antibio- tiques progresse plus rapidement que la d6couver- te de nouvelles mol6cules de ceux-ci. La chimio- th6rapie semble aussi une m6thode peu efficace. L'auteur s'oriente vers l'utilisation des tendances naturelles de l'organisme dans la lutte de celui-ci contre l'infection de l'os. Les nombreuses observations cliniques faites par l 'auteur s'appuient aussi sur l'6tude exp6rimentale. Celle-ci porte sur 60 lapins chez lesquels un module ost6omy61itique a 6t6 d6velopp6. Le traitement le plus efficace d'une ost6omy61ite exp6rimentale du tibia est une large exposition de la zone infect6e de l'os, s6- questrectomie des parties en voie d'61imination naturelle et la mise/~ nu de l'os restant.

Apr~s quelques jours se manifeste l'action natu- relic du bourgeon charnu jeune. Son r61e est double : il constitue une barri6re infranchissable contre l'infection et 61imine en m~me temps un couche superficielle, tr~s mince, d'os infect6. Dans un d61ai de quelques semaines, parfois de quelques mois, se produit la cicatrisation sponta- n6e, complete et d6finitive. Aucun antibiotique n'est administr6 dans la m6thode 6tudi6e. Parfois une greffe cutan6e peut ~tre indiqu6e pour acc616- rer le processus de gu6rison.

Mechanical and roentgenographic evaluation of vascular segmental cortical autografts. P.C. Dell, and H. Burchardt, Department of Orthopaedics, P.O. Box J-246, JHMHC, University of Florida, Gainesville, Florida, 32610, U.S.A.

Introduction: Segmental defects in major long bones of the skeleton have been variously manag-

[ed. Free vascularized bone grafts have been reported and successfully applied in chronic os- teomyelitis, irradiated tissue, and congenital tibial pseudarthrosis. However, the reparative process in vascularized bone grafts has been incom- pletely reported. For these reasons, the objectives of this experimental study were to determine and compare the incidence and time of union, and the torsional strength of vascularized autogenous fibular cortical bone grafts to similar conventional grafts. Concomitant with the experimental studies, clinical cases were performed and evaluated in 10 patients. Methods and Materials: Experimental studies: Six groups of adult mongrel dogs were used. Three types of grafts were performed: conventional, cuff, and vascularized. The vascularized graft included the patent, non-traumatized arteriovenous supply to the periosteal and endosteal surfaces. A four centimeter graft was obtained in all procedures. Animals were sacrified at 2, 6, 12, and 24 weeks after transplantation to dis- cern the vascularized and conventional graft differences. The grafts were mechanically tested to failure by rapid torsional loading. Roentgenogra- phic features of repair and the incidence of union were recorded by biweekly x-rays. Viability of all grafts was determined histologically.

Clinical studies: Vascularized fibular bone grafts have been utilized in 10 reconstructive procedures. The fibula was exposed with a 2-3 mm.


soft tissue cuff circumferentially. The fibula was then transferred to the reconstructive site and sta- bilized with an external fixator. The peroneal artery was then anastromosed to the selected recipient artery.

Results and Discussion: Experimental studies: Fifty-three dogs were evaluated in the study. The roentgenographic features of the three grafts were almost identical, except the conventional graft tended to have more peripheral callus. The incident of graft-host union or the time that union occurred was similar in the vascularized and conventional grafts. Mechanical strength analyses indicated that at twenty-four weeks conventional and periosteal cuffed grafts were the same. However, vascularized grafts were significantly stronger at six weeks than conventional grafts. Thereafter, both grafts had similar mechanical properties. From our clinical experience, the transfer of a viable bone graft was a successful approach to chronic infected non-unions, resistant to conventional treatment modalities. Additionally, the transfer of normal surrounding cellular elements and viable bone was successful in the treatment of congenital pseudarthrosis.

lntracortical bone perfusion and aspirin anticoagulation or denervation. U.K. Luethi*, R.D. Stroud*, B.A. Rahn**, S.A. Brown*.

Osteoporosis after internal fixation has been at- tributed to a biomechanical mode. Impaired intracortical blood supply beneath implants indicates that perfusion may also have a significant role during the early stage of remodeling. The following project was designed to study the effects of anticoagulation or vasodilation on these intracortical blood flow deficiencies beneath implants. Aspirin anticoagulation was used to prevent platelet aggregation and their adherence in small vessels under slow flow conditions; the sciatic nerve was cut in order to interrupt the autonomic nerve supply to the tibia thus achie- ving maximal dilation of the vessels. Disul- phinblue was used to monitor bone perfusion indicating lack of circulation by the absence of blue dye. 50 MPa pressure was applied by a 4 mm diameter plunger into the medial aspect of intact sheep ti-

biae for a period of one hour. The leg was sus- pended through the femoral condyles with a threaded rod and fixed with a lag-screw through the proximal metatarsus. Fifteen minutes preter- minal, disulphinblue (150mg/kg) was administer- ed and immediately after the sheep were sacrificed, the bones were frozen, lyophilized and the nonperfused, nonstained areas were quantitative- ly evaluated. Three groups were studied; controls, those receiving 1.3 g aspirin orally and those with the cut sciatic nerve. Without reaching the ultimate strength of bone (150MPa) an unstained bone area was always found beneath the plunger indicating that the intracortical blood flow was impaired by the applied pressure. There was a wide range of variation with the largest defect areas in the control group, followed by the aspirin anticoagulation group; the smallest blood supply deficiencies were found in the group with the denervated tibiae. Other recent works showed that these perfusion deficiencies stay for as long as 8 weeks, therefore it is felt that the possibility of decreas- ing them could be beneficial to the early stage of fracture healing.

* Orth6paedic Res. Lab. University of California, Davis. ** Labor f. experimentelle Chirurgie, Davos, Switser- land.

Preradiographic evidence by radionuclide scintimetry of femoral head necrosis following hip fracture. G. Bauer, L.I. Hanson, J. Palmer, B. Stromqvist - Depart. Orthop. Surg. University Hosp. Lund - Sweden.

In a prospective series of femoral neck fractures the metabolic state of the femoral head, repeated- ly examined by radionuclide scintimetry, was compared with the clinical course and radiographic evidence of necrosis during 1-3 years. At regular intervals each case was scanned for uptake of 99-mm technetium labelled methylen- ediphosphonate. In the early stage of fracture repair (0-4 weeks) four types of femoral head images were observed. Out of 46 hips, 11 hips had enhanced activity, 10 showed activity equal


to that on the intact side, 2 hips partially reduced activity, and 23 significantly reduced activity. There was a dramatic change in the activity pattern after four months. Only 6 out of 46 femoral heads had filling defects at the 4 month control and this tendency was retained at the 8 and 12 month investigations. In cases with initial filling defects the majority have thus had enhanced activity at later investigations, and very few have had permanent radionuclide evidence of impaired metabolism. There was a strong correlation between the early postoperative image and the clinical course. Out of the 21 cases with metabolicaly normal femoral heads, the 18 survivors went on to uneventful healing without evidence of necrosis. By contrast, the group with early evidence of metabolically deficient heads had a high incidence of compli- cations. Among 22 survivors, only 4 went on to uneventful healing, 7 had displacement of the fracture, 3 pseudarthrosis, 7 necrosis and 1 chon- drolysis. None of the 20 cases with metabolically active heads have had any secondary procedure versus 13 secondary hip replacements in the deficient group. Subsequent experience has confirmed the observations in this series : cases of intracapsular fracture of the neck of femur with normal or better postoperative radionuclide activity in the femoral head will achieve union of the fracture and segmental collapse will not develop. Fractures with subnormal femoral head activity run a high risk of redislocation and/or radiographic evidence of necrosis. The rationale for doing a primary hip arthroplasty in displaced fractures of the femoral neck is that 50 % of the femoral heads will succumb to necrosis. Our data show that many hip fractures could be saved from arthroplasty by the predictive capacity of the radionuclide image which is superior to conventional radiography. Further investigations have furnished numeric evidence that the nailing procedure may add to the initial trauma and tip the balance towards critically poor vascularity. Less traumatic nailing procedures may substantially reduce the incidence of non-union and structural collapse.

The "Conservative" management of avascular necrosis of the femoral head. M.E. Steinberg, G.D. Hayken, D.R. Steinberg, University of

Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104. U.S.A.

Although a number of methods have been described for the surgical treatment of avascular necrosis, there is a lack of agreement as to their effectiveness. This is partially because there is little objective information about the results of non-operative management against which these might be compared. Many clinicians therefore continue to advocate "conservative" treatment with restricted weight-bearing in anticipation of spontaneous healing. We have reviewed 250 cases of avascular necrosis seen between 1970 and 1980 and have evaluated the results of non-operative management in 55 hips with sufficient follow-up time. In addition to clinical parameters, we used a new system of radiographic evaluation and staging which included the use of bone scans, point counting, and planimetry. Of 16 hips seen initially prior to subschondral collapse (crescent sign), 13 showed progressive sclerosis and cyst formation and 11 of these went on to collapse. In 3 there was no clear progression, and 1 showed apparent healing. Of 11 hips seen after the appearance of the crescent sign, 9 showed progression. Of 28 hips seen with flattening of the articular surface, 27 progressed and the majority of these required replacement surgery. There were no differences between hips treated with limited or non-weight bearing and those in which full weightbearing was allowed. These observations clearly point out that the majority of cases will, progress with "conservative" management and give us a basis against which to compare the effectiveness of our surgical proce-

�9 dures. Supported in part by a grant from the PEW Foundation through the Eastern Pennsylvanic- Chapter of the Arthritis Foundation.

Oxyg~noth~rapie hyperbare dans les ost~on~croses de la t~te f~morale. J.M. Baixe - Toulon, France.

Retomb6e th6rapeutique de la plong6e, la m6deci- ne hyperbare qui utilise les hautes pressions d'at- mosph&e artificielle, d'oxyg~ne en particulier, a de nombreuses indications dont les isch6mies osseuses. Le principe consiste ~t dissoudre l'oxyg~ne dans les tissus en fonction de la pression partielle de

330 Clinical rheurnatology, 1982, 1, N ~ 4,

cet oxyg~ne qui est ionis6. L'os est une substance piezzo-61ectrique sensible ~ la pression: l'hypo- pression d6min6ralise, l'hyperpression calcifie. Le traitement des art6riopathies par l'oxyg6no- th6rapie hyperbare est d6jh bien admis. Dans les ost6on6croses de la t&e f6morale, que l 'on peut consid6rer comme des isch6mies osseuses dues l'oblit6ration des petites art6rioles par des throm- bus 6rythrocytaires, ou lipidiques, I'OHB stoppe l'effondrement et 6vite le recours ~ la chirurgie, r6alisant un v6ritable "forage". La technique consiste en des s6ries de 10 s6ances d'une heure, h la pression de 2 ATA 3 renouve- l~es assez pr~coc~ment. Le protocole du traitement est simple et les contre-indications ne sont qu'O.R.L. (dysperm6abili- t6s tubaires). Les r6sultats sont favorables lorsque l'ost6on6- crose est trait6e avant les destructions.

Treatment of avascular necrosis o f the femoral head with electrical s t imulat ion - a preliminary report. M.E. Steinberg, C.T. Brighton, G.D. Hayken, S.E. Tooze, D.R. Steinberg, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104. U.S.A.

Because avascular necrosis affects primarily younger adults, the goal of therapy is to preserve rather than replace the femoral head. Although a number of procedures have yielded promising re- suits, we must continue to search for even better methods of management. During the past 10 years we have had consider- able experience with the use of direct current stimulation of bone under both experimental and clinical conditions. Bone formation is enhanced and established non-unions have been healed in 85 ~ of the cases. Because of the dramatic effects of this technique, we have recently begun to app- ly it to the treatment of avascular necrosis of the femoral head. To date, 20 hips diagnosed before collapse of the femoral head, were treated with "core decom- pression", grafting, and the insertion of direct current electrodes. The surgical technique will be described in detail. These cases were compared with hips managed nonoperatively, and with those treated with either drilling alone or with drilling plus grafting. The results were determined both clinically and radiographically using a new method of staging and evaluation which em-

ployed point counting, bone scans, and planimetry. Although it is too early to draw definitive conclusions, the results to date have been gratifying and have been better than those obtained with other techniques. Preoperative pain has been relieved and there has been no evidence of progression to date. Supported in part by a grant from the PEW Foundation through the Eastern Pennsyllvania Chapter of the Arthritis Foundation.

Treatment of osteonecrosis with pulsed electromagnetic f ie lds: an interim report. C .A .L . Bas- sett, M.M. Schink, and S.N. Mitchell,. New York Orthopaedic Hospital, Columbia Presbyte- rian Medical Center and Orthopaedic Research Laboratories, New York, N.Y. USA.

In 1981, the authors reported successful treatment of osteonecrosis of the hip with pulsed electromagnetic fields (PEMF's) ~. The present study extends the numbers of patients, their follow-up and defines patterns of response. PEMF's continue to be beneficial in Ficat II w III lesions, whether idiopathic or steroid, alcohol or trauma induced. No patients with Ficat I lesions or surgery within 6 months of PEMF's were included. Treatment with hip coils 10 hrs/day, constituted the only change in initial patient management. Since 1979, 45 hips in 40 patients have been followed, a mean of 1 year (range 6-37 months.) The average age was 38.6 years. 29 hips, followed 1 year, had an average pain grade of 3.6 to 5.2. No patient failed to improve in both categories. 1l patients with 16 hips, followed between 6-12 months also demonstrated improvement in pain and function, but not to the same grade level as patients treated for a year. A few Ficat IV patients were included in the series, although improvement in pain and function was observed in these patients, it is much too early to predict the ultimate fate of these hips. Radiographically, no joint narrowing has been observed nor have mar- ginal osteophytes appeared if not present at the outset of treatment. Head contour has not changed beyond that present when the patient entered the program, despite weight-bearing for the major portion of the observation period with one exception. Minor collapse occurred in 2 patients on continuing steroids. Crescent signs have disappeared in many patients and most have demonstrated changing

Clinical rheurnatology, 1982, 1, N ~ 4, 331

patterns of rarification and density suggestive, but not conclusive of healing. Responses in patients with osteoarthritic changes have been less satisfactory. Control of pain, im- proved activity and an arrest of femoral head collapse have been hallmarks of the study in patients with advanced disease treated for a year. The cautious optimism expressed in the earlier report appears justified. PEMF's may provide a means for aborting progress of pathologic changes, particularly if they can be applied earlier, during the Ficat I stage.

REFERENCE

1. BassetC.A.L., SchinkM.M. and MitchellS.N. : Pulsing electromagnetic field effects in avascular necrosis: A preliminary report. Tran. Bioelect. Repair and Growth Soc. 1 : 38, 1981.

Essai de r~vascularisation de la t~te f~morale dans les n~croses primitives et post traumatiques. (Premiers r6sultats) H. Judet, A. Gilbert, J. Jude, 6 square Jouvenet, 75016 Paris, France.

Depuis Juillet 1978, nous proposons une technique originale dans le traitement des n6croses de la t~te f6morale : - La t~te f6morale est lux6e en avant. - La coquille d'oeuf ost6o cartilagineuse est sou- lev6e. - L a n6crose osseuse est excis6e en totalit6 jusqu'en os sain. Elle est remplac6e par de l'os spongieux iliaque. - Au sein de cet os spongieux est introduit par la face ant6rieure du col une diaphyse p6roni~re pr61ev6e du c6t6 oppos6 avec son p6dicure vasculaire. Celui ~i est anastomos6 en utilisant les techniques de micro chirurgie au p6dicule circonflexe revascularis6. - La coquille ost6o cartilagineuse est alors rabat- rue et sutur6e. Apropos des 20 premiers cas op6r6s ayant au moins 2 ans de recul, les indications sont pr6ci- s6es et les r6sultats analys6s.

Stress distribution in the femoral head fo l lowing cortical bone grafting for aseptic necrosis. H .B . Skinner, A.R. Penix, S.D. Cook, R.J. Haddad, Jr. Department of Orthopaedic Surgery, Tulane

University School of Medicine, New Orleans, Louisiana, U.S.A.

Aseptic necrosis occurs in the post traumatic and idiopathic forms and in either is due to disruption of the blood supply to the femoral head. The treatment of aseptic necrosis of the femoral head has been directed towards revascularization of the femoral head. Active forms of treatment of the early lesion in aseptic necrosis of the femoral head are directed towards speeding this revascularization. Core drilling of the femoral neck and head to "decompress" and to permit stimulation to revascularization of the femoral head is one proposed method of treatment. An alternative mode is core drilling followed by cortical bone grafting with a fibular strut graft. Inconsistent results of the use of these two methods have been reported. The purpose of this study was to evaluate the effects of drilling with both correct and incorrect cortical bone grafting on the stress distribution in the femoral head treated for aseptic necrosis. Two dimensional plane stress finite element models of an intact femur and femurs which contain- ed an incorporated cortical bone graft (fibular strut) from the lateral cortex to the subchondral plate, a cortical graft placed short of the subchondral plate leaving a void in the grid, and a femur which was drilled with a single drill hole (but not grafted) were constructed. The results of the stress analysis were obtained for the intact femur, femur with a properly placed graft, an improperly placed graft and a drilled but ungrafted femur. The results indicate that a cortical graft placed along the femoral neck and into the superior and lateral femoral head significantly reduced stress levels in the surrounding subchondral bone by as much as 50 % compared to the intact femur. A drilled but ungrafted femur showed no stress reduction with selected areas of the head having demonstrated increased compressive stresses. Improperly positioned grafts placed short of the subchondral bone (after drilling to the subchondral plate) actually increased the compressive stresses in the superior and lateral femoral head. The results suggest that a properly placed cortical bone graft will stress relieve an avascular segment of the femoral head while simple drilling or im- proper graft placement will increase stresses on the avascular segement making collapse of the head more likely. Reported failure of core drilling with or without bone grafting may be attri-


buted to suboptimal surgical technique with re- sultant mechanical failure rather than failure of the revascularization concept. Supported by the Veterans Administration.

* D6partement d'Anesth6sie-R6animation (Professeur Jolis). ** Service de Chirurgie Orthop6dique (Professeur De- burge), Universit6 Paris 7, H6pital Beaujon, 92118 Cli- chy C6dex, France.

Traitement de I'algodystrophie reflexe par la r~- serpine intra-veineuse. C. Nedjar* et C. Ficat**.

D~s ses premieres descriptions par Destot (2), puis Sudeck (4), le syndrome algodystrophique r6flexe post-traumatique a 6t6 attribu6 h un d6r~- glement du syst~me sympathique. Cette th6orie a connu son apogee avec les travaux de Leriche (3). L'utilisation de la r6serpine, qui provoque une d6pl6tion du pool granulaire des cat6cholamines, au niveau de la terminaison des fibres post-gan- glionnaires, parait int6ressante pour bloquer le sympathique, d'autant que l'effet d 'une injection dure plusieurs semaines (1). Nous avons trait6 17 patients: 11 femmes et 6 hommes, dont l'fige moyen 6tait de 49 _+ 7 ans. L'affection 6tait localis6e 9 fois au membre sup6- rieur (3 syndromes 6paule - main, 6 mains + poi- gnets) et 8 fois au membre inf6rieur (1 atteinte de la hanche et du genou, 2 genoux, 1 rotule, 4 che- villes).Le traumatisme 6tait l'6tiologie habituelle (2 entorses, 12 fractures, 2 plaies nerveuses sutu- r6es). Un cas faisait suite h u n zona. Tous les patients pr6sentaient un certain degr6 d'alt6ration psychologique (hyper-6motivit6, d6pression). La technique consiste en une anesth6sie loco-r6gio- nale intraveineuse avec, pour le membre sup6- rieur 1 mg de r6serpine associ6 h 20 ml de lido- caine ~t 1 p. 100 et pour le membre inf6rieur 1,5 mg de r6serpine associ6 ~t 40 ml de lidoca~ne ~t 1 p. 100. La lidoca~ne rend le port du garrot sup- portable pendant 45 minutes. Une seule injection a 6t6 n6cessaire. La douleur disparait quelques minutes apr~s l'injection ; ceci est imm6diat et durable. L'anesth6sie permet une mobilisation pas- sive du segment de membre atteint; le gain est 6galement appr6ciable, pr6coce et durable. D~s l'ablation du garrot, le membre prend une nette coloration rouge qui s'accompagne d'une sensa- tion de chaleur, faisant disparaitre la fr6quente impression de froid. Le traitement est suivi de la r66ducation habituelle. Cette technique simple et prometteuse ne n6cessite que quelques heures de surveillance, mais en milieu hospitalier avec une infrastructure de r6animation, en raison des effets secondaires possibles de la lidoca~ne et de la r6serpine.

Evaluation of the vascular effect of calcitonin treatment in reflex sympathetic osteodystrophy. M.F. Driessens, P.P.G. Blockx and G. Mortier. Akademisch Ziekenhuis Antwerpen, 2520 Ede- gem - Belgium.

The vascular aspect of reflex sympathetic osteodystrophy (RSO) is still a matter of debate. In the present study, vascularisation parameters were estimated by means of a dynamic blood pool imaging procedure using 99m Tc labelled human serum albumin. In early RSO a higher blood volume was conse- quently found in the affected limb. Control scans during and after calcitonin therapy showed a progressive decrease in blood volume to levels comparable to those found in the unaffected limb, in case of successfull treatment. These findings suggest that in humans part of the effect of calcitonin in early RSO may be related to a direct vasomotorical action, as appeared in previous animal experiments (1), (2). Moreover, these results indicate that the described method may be used as diagnostic tool in RSO, and as a parameter in its treatment with calcitonin.

REFERENCES

1. Am. J. Physiology. Vol. 241, H91-H94, 1981. 2. Revue du Rhumatisme, nr. Sp6c. P7, 1403, 1981.

Diagnonis and treatement of osteonecrosis of the knee. b. C.H. Bauer - Department of Orthopaed- ic Surgery, Lund University Hospital, S-221 85 Lund Sweden.

Until 10 years ago osteonecrosis of the knee was virtually unknown. We now know that some of the most serious ans rapidly progressive types of osteoarthritis of the knee may be secondary to osteonecrosis. The condition characteristically appears in ortherwise healthy elderly people. The mode of onset is usually sudden with severe rest pain on the inside of the knee, usually aggravated on weight-bearing. In the initial stage clinical findings are meager; only tenderness over the

medial femoral condyle, sometimes a slight swelling, rarely an exsudate. Radiographic examination during the initial months after onset of pain is usually normal or, at most, shows a barely visible flattening of the medial femoral condyle. Within 2-6 months a characteristic radiographic lesion develops with a radiolucent zone surrounded by a sclerotic halo. The prognosis is usually not good. Eventually most cases develop osteoarthritis, some very rapidly within a few months, most slowly over the course of years with a radiographic appearance undistinguishable from idiopathic osteoarthritis. During the radiographically silent interval, radionuclide scintimetry may aid in the differential diagnosis between osteonecrosis, meniscal lesions, and fatigue fractures of the medial tibial condyle. Therapy in early stages aims at prevention of cartilage destruction and in late stages to reconstruction of the weight-bearing joints surfaces. In healthy patients below 70 a tibial osteotomy may relieve weight-bearing at the medial femoro-tibial articulation sufficiently to permit the condition to heal without further destruction of the joint. In more severe cases and especially in the elderly a uni- compartment arthroplasty is advocated since the lateral articulation is not affected and the size and shape of the osteonecrotic lesion in the medial femoral condyle has developed according to the same biomechanical laws as the femoral com- ponent of the surface endoprosthesis.

Correlations entre d6bits sanguins osseux et pressions intra m6dullaires. G. BouteiUer*, A. Bias- co, F. Vigoni, J.L. D6camps.

Les auteurs ont mesur6 de fa~on simultan6e les d6bits osseux et la pression intra-m6dullaire (P1M) chez 12 chiens adultes anesth4si4s. Les d6bits sont mesur6s par la m6thode des mi- crosphhres radioactives (diam6tre des microsph6- res: 15 um). Les PIM en mmHg sont mesur6es dans le f6n~ur (trochanter et diaphyse), et dans la diaphyse tibiale, grace ~ un trocart de 1,40 mm de diam~tre. Apr~s injection des microsph6res et prise de pression, les segments osseux consid6r6s sont r6cup6r6s pour comptage de la radioactivit6 et calcul des d6bits en ml/mm/100 g. Rdsultats: Chez 4 chiens, en ne mesurant la pression que d 'un seul c6t6, on s'est assur6 que la symm6trie des d6bits entre !es c6t6s D et G, 6tait


quand m~me respect6e. Pour des PIM inf6rieures h 15 mmHg, les PIM de la diaphyse f6morale et du trochanter tendent ~t se confondre. Pour les valeurs sup6rieures, les PIM de la diaphyse f4mo- rale sont toujours sup6rieures de 30-45 ~ aux PIM trochant4riennes. Les PIM tibiales sont plus variables, mais toujours proches des PIM f6mo- rales. Les valeurs des d6bits osseux, au contraire respec- tent toujours la m~me hi6rarchie, avec par ordre d6croissant : le trochanter, la diaphyse f6morale (~t l'inverse des PIM), puis la diaphyse tibiale, avec des 6carts toujours consid6rables. Le d6bit du trochanter peut ~tre jusqu'~t 40 fois sup6rieur

celui de la diaphyse tibiale. Conclusions: La prise de PIM ne semble pas mo- differ de fagon importante les d6bits sanguins locaux. Les relations d6bits-PIM sont variables se- Ion les r6gions osseuses consid6r6es, si bien qu'une valeur de PIM ne peut ~tre le reflet d'une valeur de d6bit osseux.

* Centre Hospitalier, route de Tarbes, 32011 Auch, France.

Experimental arthritis of the juvenile knee. C. Bringer, E.H. B0nger, J. B01ow, J.C. Djurhuus. Orthopaedic Hospital, Department of Pediatrics, Aarhus Kommunehospital and Institute of Expe- rimental Clinical Research, University of Aarhus, DK 8200, Denmark.

An animal model suitable for the study of hemodynamics in juvenile arthritis is presented. Uni- lateral arthritis was induced by weekly injections of 2 increasing to 3 ml 1 070 solution of the muco- polysaccharide Carragheenin into the knees of 8 weeks puppies. The arthritis was documented on serial radio- graphs, histomorphometry of epiphyseal bone and histological investigation of synovial memb- ranes. A multichannel constant rate perfusion system with transcutaneous transcortical bone cannu- lation was used for simultaneous intraosseous and intra-articular pressure measurements. Tissue blood flow investigation was performed by tracer-microsphere technique. Central haemo- dynamic control included cardiac output, mean arterial pressure, central venous pressure, core temperature and blood gases.


Histog~n~se et histophysiologie de la vascularisation des cartilages ~piphysaires chez le foetus humain. D. Chappard, J.L. Laurent, C. Alexandre, G. Riffat. Laboratoire de Biologie du Tissu Os- seux, U.E.R. de M6decine, 30 rue Ferdinand Gambon, 42023 Saint-Etienne Cedex. France�9

Le squelette foetal humain est mis en place d6s la 8 ~ semaine chez l 'homme, sous forme de maquet- tes cartilagineuses pour sa plus grande partie. L'ossification d6bute ~ la 9 ~ semaine et aboutit la constitution des plaques de croissance isolant les 6piphyses cartilagineuses de la diaphyse. A la 10 ~ semaine, les 6piphyses atteignent une masse critique ~ partir de laquelle on observe l'apparition de canaux intrachondraux, v6ritables expansions du p6richondre, contenant un syst6me vasculaire rudimentaire. Celui-ci permet les ap- ports nutritionnels pour les cellules situ6es au centre de l'6piphyse. A partir de la 17 ~ semaine, il existe une augmentation consid6rable des canaux intrachondraux (27 syst~mes ind6pendants au niveau de la t~te f6morale). La complexit6 des r6seaux vasculaires intra-canalaires augmente. On distingue morpho- logiquement trois types de canaux : - les canaux superficiels sous-articulaires, - les canaux profonds centro-6piphysaires, - les canaux perforant la plaque de croissance, dont la vascularisation est d'origine diaphysaire. Les canaux intrachondraux ont trois r61es dis- tincts : �9 Ils assurent la vascularisation au centre de l'6pi- physe ; �9 Ils permettent une chondrog6n6se p6ricanalaire et centrifuge au centre de l'6piphyse ; �9 Ils jouent un r61e important dans l'apparition du point de min6ralisation 6piphysaire. Cette vascularisation cartilagineuse, mal connue ~t l'heure actuelle, persiste chez l 'enfant au niveau de certaines 6piphyses jusqu'h 13 arts environ�9 Nous avons r6alis6 une 6tude par injections intra- vasculaires compl6t6e par une 6tude en microscopie optique.

A study of 133 xenon washout rates from the synovial cavity in experimental osteoarthritis. S�9 Christensen, I. Reimann, O. Henriksen, C. Ar- noldi, Department of Orthopaedic Surgery - Rigshospitalet - Blegdamsvej 9 - DK-2100 O. Denmark.

Synovial perfusion in 6 rabbit knees, with experi- mentally induced osteoarthritis (joint instability),

was studied by recording the initial 133 xenon washout rates from the joint space. The unstable, osteoarthritic knee was compared with the contralateral sham operated control knee at intervals of 6 to 96 weeks postoperatively. Within the first half year the ratio between the 133 Xe washout rates in the osteoarthritic and control joints was significantly increased. These findings were supported by the increased blood flow to the joint region, visualized by scintigraphy of osteoarthritic rabbits given 99 m Tc-microspheres intracardi- ally. However, methodological sources of error do not allow any conclusions regarding the much less increased 133 Xe washout rates found in advanced osteoarthritis. The initially increased synovial blood flow coincided with the existence of joint effusion and the early development of osteophytes, all conditions supposed to be a consequence of posttrau- matic synovitis. Attention is drawn to these par- thogenic phenomena in studies dealing with the initial changes in experimental models of os- teoarthristis and to a possible etiological significance.

"Invasion vasculaire ferrule m6taphysaire du cartilage de croisance". D�9 Robles Marin, R�9 Brose- ta, J�9 Berlabga, M�9 Aranda, M. Marti, P. An- dreu. Dpto. Anatomie Prof. Smith-Agreda. Va- lencia - Espana.

La terminaison des capillaires d'origine metaphy- saire, h la zone d6g6nerative du cartilage de croisance, a 6t6 consider6e ouverte par la plupart des auteurs (Van tier Stricht, 1982; Lewis, 1958; Trueta et Morgan, 1959; Schoelf et Clif, 1963), ne serait-ce que occasionellement (C.E. Anderson et J. Parker, 1966)�9 Pourtant dans des reconstructions ~t des forts grossissements avec la microscopie 61ectronique, nous captons ces terminaisons vasculaires toujours ferm6es jusqu'~ pr6sent, cela nous fait penser que l'hypothese de Brookes et Landon (1954) pour des embryons est digne d'etre consider6e aussi pour l'adulte.

Osteonecroses posttraumatiques de I'astragale: Facteurs de risque, prevention. F�9 Schuind, Y. Andrianne, F. Burny, M�9 Donkerwolcke, O�9 Sa- ric.

359 fractures et luxations de l'astragale trait6es dans 15 centres beiges et fran~ais de traumatologie entre 1961 et 1980 ont 6t6 revues.


L'incidence de l'ost6on6crose est de 32,5 %. Di- vers facteurs de risque ont identifi6s : 1. Type de ldsion : La n6crose touche surtout les 16sions d6plac6s (d~placement 2 mm. n6crose: 35,5 %). Toute- fois les 16sions sans d6placement ne sont pas sans danger (n6crose: 26,9 %). Parmi les fractures du cot, le risque de n6crose est plus 61ev6 pour le type II (luxation sous-astragalienne du fragment pos- t6rieur : risque : 46,0 %) et le type III (6nucl6ation du fragment post6rieur: risque: 60,6%) que pour le type I (sans d6placement: risque: 24,4%). L'ost6on~crose complique particuli~re- ment fr6quemment les fractures de la trochl6e (risque: versant externe 37 ,1%; versant interne 42,6%), les fractures comminutives (risque 73,86 %) et les 6nucl6ations qui s'accompagnent n6cessairement d 'une suppression totale de la vascularisation (risque 90,8 %). Par contre, les fractures des tubercules, de la t~te et les luxations simples se compliquent rarement de n6crose (risque: tubercule lat6ral 14,5 %; tubercule post6- rieur 7,5 %; t~te 0,0 %; luxation tibio-astragalienne 0,0 % ; luxation sous-astragalienne et m6- dio-tarsienne 3,6 %), 2) Type de traitement : L'ost6on6crose complique plus souvent les 16sions astragaliennes op6r6es (risque: traitement ortho- p6dique 25,0 %; traitement chirurgical 39,4 %). S'il existe incontestablement un facteur de d6vas- cularisation n6cessairement li6e h l'acte chirurgical, notons cependant que les fractures ou les luxations r6duites de manibre sanglante 6talent plus souvent d6plac6es. 3) Qualitd de la rdduction : Une r6duction anatomique favorise la revascularisation de l'astragale et pr6vient ainsi partielle- ment I'ost6on6crose (risque: r6duction m6diocre 30,5 % ; r6duction anatomique 18,5 %). Dans notre statistique, ni l'fige du patient, n i l e d61ai accident -manoeuvres de r6duction ne modi- fient significativement le risque de n6crose.

* Service d'Orthop6die-Traumatologie, Cliniques Uni- versitaires de Bruxelles, H6pital Erasme, 808, Route Lennik, B - 1070 Bruxelles, Belgium.

A new method for evaluation and staging of avascular necrosis of the femoral head. M.E. Steinberg, M.D., G.D. Hayken, M.D., Universi- ty of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104. U.S.A.

Although a number of systems have been described for staging or grading the hip in avascular

necrosis, each has significant limitations. The ideal method should be simple yet precise, objective and sensitive. It should be useful as both a clinical and research tool. The method which has been developed depends entirely on AP and lateral roentgenograms of the hip and Technetium diphosphonate bone scans. Although the clinical status of the patient is evaluated carefully, it does not enter into the staging per se. The type of pathological change is determined initially and places the hip in Stage 0 to VI. The extent of involvement is then measured by the use of point counting, concentric circles, and planimetry. (For strictly clinical purposes, a simple es- timate of "mild" , "moderate", or "severe" would generally suffice) :

Stage 0 - Normal x-ray, normal bone scan Stage I -Norma l x-ray, abnormal bone

scan Stage II - Sclerosis and/or cyst formation

in femoral head A - Mild (( 20 %o); B - Moderate (20 %0-40 %0) ; C - Severe 040 %0)

Stage III -Subchondral collapse (crescent sign) without flattening A - Mild (( 15 %) ; B - Moderate 15 %-30 %) ; C - Severe () 30 %)

Stage IV - Flattening of head without joint narrowing or acetabular involvement A - Mild (( 15 % of surface and ( 2 mm depression); B - Moderate (15 %-30 % of surface or 2-4 mm depression); C- Severe () 30 %0 of surface or ) 4 mm depression)

Stage V - Flattening of head with joint narrowing and/or acetabular involvement A - Mild; B - Moderate; C- Sev- ere (determined as above plus es- timate of acetabular involvement)

Stage VI - Advanced degenerative changes

This technique has been used to evaluate 250 hips and has proven simple, reproducible, and precise. Small changes can be measured and the progression of the disease can be determined accurately. Thus it should allow us to evaluate the effectiveness of various therapeutic measures, should aid in establishing a prognosis, and should help to determine the outcome of treatment.


Supported by a grant for the P E W Foundat ion through the Eastern Pennsylvania Chapter fo the Arthritis Foundation.

La rh6ologie sanguine dans la recherche 6tiologi- que des ost~on~croses. Taberly*, Pradere**, Re- gis**, Bru**, Bouzet***, Mazi6res***, Arlet***.

Par cette 6tude nous tentons de r6pondre h la question suivante : existe-t-il chez les malades atteints d'ost6on~croses de hanche un trouble rh6o- logique sanguin ? I1 semble en effet se confirmer qu 'h c6t6 de troubles plus connus (microtraumatismes ou troubles vasculaires locaux) il existe un facteur de risque plus g6n6ral li6 h une modif icat ion de la r6gula- tion de la viscosit6 lors de l '&oulement dans la microcirculation. L'exp6rimentation a port6 sur 12 cas d'ost6on6- croses de hanche de stade III et IV et 56 sujets t6moins (30 donneurs de sang et 26 polyglobuli- ques). Pour chaque 6chantillon de sang veineux, pr61ev6 au pli du coude, le rh6ogramme (enregistr6 sur rh6om&re RV 100 CV 1001 mod61is6), a permis de d6terminer 5 param&res. Le module th6orique utilis6 &ant le suivant :

n o + n~ Ik I r = k

1 + ~k Ikl

k: gradient de vitesse du rh6om6tre r : contrainte de cisaillement Aux 3 param&res n 0, n% 1 de ce module, nous avons ajout6 les 2 param&res

DE : n~ , K = n o - n ~ Xn~o ~2

Une &ude statistique multifactorielle et plus pr6- cis6ment une analyse discriminante a .permis , h partir de ces 5 param&res rh6ologiques, de distin- guer les ost6on_~croses des cas t6moins, confor- tant ainsi l 'hypoth6se dans les 6tiologies des os- t6on6croses d 'un trouble g6n&al de l 'adaptat ion sanguine/ t l '6coulement.

* lnsa Service de Math6matiques, Av. de Rangueil, Toulouse. ** Service de Biophysique, CHU Toulouse, Rangueil, France. *** Service de Rheumatologie, CHU Toulouse, Ran- gueil, France.