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Copright
hy The Journal
985
of Boi,e
and
Joittt
Surgery.
ltteorporated
For
technical
Correspondence
To
the
Editor:
and
Viability
position
delightful.
Wong
nomenon
of the
of bone:
(I)
reading
et al. have,
mostly
beside
of sections,
without
underlying
them:
plates
Effect
Head”
like
the groups
of principal
association
to discontinuities
and
(4) on the
associated
found
sturdy
Corn-
Feb.
1985)
that
in two-millimeter-thick
(2)
in
majority
of cancellous
marrow
considering
the relationship
and the bone
the assumption
accretions
that
woven
bone
mature
trabecula
it is one
heads
been
I felt that one
between
the state
be to study
From
way
and
a study
accretions
with
viability
of
and without
discontinuities
shown
than
an
trabecula
and
increased
density
artefact.
there
yet
can
no
a manifest
that
of bone
bone
might
with
causes
We
identify
osteoclasts
which
identifies
using
Thus,
when
activity.
standard
there
We
doubtless
( I ) did
near
1 1 was
if the
resorption
an
authors
near
the
near
of
of marrow.
to identify
any
were
were
prepared,
as acid
phosphatase
activity
point.
figure.
have
more
although
been
lost,
incidentally,
region
been
seen,
and
to be definitive
undecalcified
a microradiograph.
Evans,
ml-
at the
is predomiwere
it is not possible
A.
of the
there
activity
cells
is a stained
than
material,
in osteoclast
have
the
phos-
in postmortem
in the
as no multinucleated
had
acid
confidence
even
is,
several
osteoclasts
particularly
may
(that
taken
in postmortem
osteoclasts
the
The
be used
they
was
cytoplasmic
times
stains,
and
sections
of osteoclasts
section
,
M.B.B.S.
not
F.R.A.C.P.
Metabolic
bone
Concord,
New
South
Unit
Concord
Hospital
2139,
Australia
Wales
intravital
might
reaction
iden-
in 0.2-mil-
unable
by their
do not
stage,
However,
than
were
removal
removal
been
presence
cannot
at an earlier
osteoblastic.
rather
we
assessed
no prior
to fifty
histological
nantly
on this
on
although
after
10, as the tissue
seven
but which
and (2) did not produce
Figure
section
time
would
with
of the
in Figure
of enzyme
crofracture
bone
was
but have
the crack
histologyt.
to loss
bone
sections,
to comment
microfractures
viability
Richard
et al.
mesenchymal
undecalcified
due
osteocyte
discontinuity.
Wong
(cracks),
I wonder
existed
in trabeculae
in their
be so much
sign
of the
associated
standard
samples.
bone.
of woven
are
death.
activity,
does
The
of calcified
to be certain
near
identification
) At
accretion
mature
osteocytes
discontinuity
on why
that
to see
the
rather
comment
the
sectioning.
or not a relationship
accretion
the
specimen.
of, for example,
before
after
matter.
sections
able
microfractures,
in them.
resorption)
hours
not
of the
of decalcified
accretions
phatase
fresh
from
the
specimens
in the
that
necessarily
stiffness
and the bone
osteocytes
with
that
(My
trabecula
disappointed
was that
in processing
in a trabecula
not
of
that
in methacrylate
I concluded
somewhat
reason
be of a different
to cracks.
of the
findings.
The
to find out whether
by conditions
atrophy
change
lead
in tra-
unfortunately
interesting
the latter
It is not possible
in making
are
region
while
reviewed
definite
-
delicate
the discontinuities
I did not feel justified
effect.
I felt
embedded
viability
my
I was
proof
would
of the underlying
the
be provoked
mention
and
it.
might
had
the time,
of bone
of cause
underlying
shrinkage
femoral
them,
of a microcallus
differential
between
near
elements,
sections
have
bone
When
is a very
limeter-thick
We
bone
long
the
this
we
in the
tified
ones.
beculae
reasons
viability
agree
in the trabeculae
and
osteocyte
accretions
(3) in the
trabeculae
the
by the pheof load:
(cracks)
elements
short
Bone
these
transmission
trabeculae:
different
with
fascinated
I have
by the
on
274-283,
become
studies,
bypassed
of Age
(67-A:
myself,
In my
in areas
-
‘The
‘
in the Femoral
microcallus.
osteoporosis
namely,
I found
care
to
outside
crack
but
1.
the
R. A.; DUNSTAN,
C. R.; and BAYLINK,
D. J.: Histochemical
Identification
of Osteoclasts
in Undecalcified
Sections
of Human
Bone.
Mineral
and Electrol.
Metab.,
2: 179-185,
1979.
EVANS,
rather
the microcallus
on the
microradiographs.
The
vations
authors
might
published
in
spongiOsem
des
want
Knochen.
Mikrokallus.
to refer
1978
to my rather
(Spontane
Beobachtungen
Zeitschr.
und
Orthop.
more
angiogene
qualitative
obser-
Knochenneubildung
Bemerkungen
Grenzgeb..
zum
116:
in
Ph#{228}nomen
Reinhard
KOlbel,
M.Sc.
Dr.
Evans
Hamburg
20,
52
Germany
replies:
were
consider
interested
it most
microfracture
and
that
it was
our
embedding
to three
found
lamellar
bone
of ethanol
during
lamellar
bone.
biopsy
was
the
original
67-A,
are
artefact.
Were
the
Kfllbel.
we
should
and
we
Hence,
have
microfracture.
NO. 8. OCTOBER
not
we think
of the
the
by gaps
discontinuity
thus
to see
the
observed
it most
one
of one
ilar.
might
up
permit
this
different
was
reduced
involve
two
groups
woven
is, during
same
it in some
talus,
did
of fractures,
principles,
one
treated
Marion
Department
reduction
is to compare
better.
of the initial
that
A more
valid
operatively
reductions
C.
Vanderbilt
Nashville,
two
no surprise
and
was
Harper.
of Orthopedic
as
groups
joint-space
to AO
It is therefore
and
two
of non-anatomical
anatomically
the quality
Study
in the
of fractures
of medial
of the
standards.
more
wherein
degree
of
Ct al.
group
according
stabilization
reduction
one
millimeters
is treated
Phillips
To compare
for
to
significance
Randomized
by
67-78).
reduction
to two
group
not
non-operatively.
simM.D.
Surgery
Medical
Center
Tennessee
37232
the stage
phenomenon
Dr.
of woven
and
hundreds
of
that the discontinuity
Phillips
Dr.
A had
replies:
Harper’s
a similar
a satisfactory
1985
for
for anatomical
that
(67-A:
and
according
the
‘A Prospective,
‘
reduction
fractures
question
Fractures’
unlike
induced,
of
areas
likely
group
study
With
quite
to be
contiguous
with
Journal
second
does
calls
‘
Ankle
a satisfactory
allows
I must
article
of the open
ankle
discontinuity
shrinkage
(that
rather
sections
a transverse
was
but
unstable
group,
in the
of The
the
certainly
groups
suggesting
issue
closed
AO
of Severe
wherein
widening
1 1 is a
of sectioning.
appearance
be able
have
serial
accompanied
only
of the specimen
trabeculae
However,
take
We
1985
managed
Figure
in all sections,
by differential
processing
in our
the process
1 1 shows
The
where
specimens.
artefacts
no gap.
dehydration),
situations
did
during
Figure
observations.
shown
We
with
Professor
in other
VOL.
such
while
pattern,
Kdlbel’s
to be present
produced
medium,
by
such
an artefact.
the discontinuity
a sectioning
suggested
of Professor
the discontinuity
than
micrometers.
of
that
not an artefact
in the lamellar
that
likely
rather
area.
to read
reached
I am an advocate
displaced
by the
Management
fractures
which
We
outlined
January
of
Although
of most
the conclusion
of the
Universitatsklinik
Martinstrasse
2000
fixation
principles
682-691).
Orthopadische
To the Editor:
internal
comments
quality
closed
are appreciated.
of initial
reduction
closed
as outlined
All of the patients
reduction
in Table
and
met
in Group
our criteria
I. We believe
that
for
many
I 303
1304
CORRESPONDENCE
physicians
would
consider
such
a reduction
ommend
continued
non-operative
randomly
assigning
such
we
to determine
the
role
of operative
The
that
the
anatomical
hoped
fractures.
in the open-treatment
group
a potential
advantage
satisfactory
closed
Finally.
I’d like
medial
26,
the
By
or non-operative
therefore
avoiding
be interpreted
of
higher
fractures
to point
out a few
was
Key
While
Lateral
Surg.
closed
not
4.8.
Also,
in the
Yablon,
Joint
and
was
I. G.: Heller,
Malleolus
59-A:
.
text,
Fractures
March
of
1977.
A.
Phillips.
Floor,
Ann
Outpatient
Arbor,
of one
reduction
use
or non-use.
Regarding
was
54
Building
Michigan
48109
The
arthritis
score,
articular
any
this
question
worth
the
of whether
that
to decide
due
Dr.
in consultation
that
The
the
supe-
method
group,
of
not
irregular
its
articular
a subjective
assessment
radiographically
and
could
surface.
We
article.
significant
difference
difference
in out-
in anatomical
is a matter
with
had
the
in the articular
in the
discusses
score.
scores
stated
‘ .
of an
as seen
to the
Weis
of
score
about
in that
was
the statistically
is primarily
risks
issue
This
clearly
we
the other’
the
incongruity
more
total
anatomical
abstract,
presence
surface
of the
conclusions
over
was
the
measurable
hopes
versa.
any
to be abnormal.
defined
which
patient
the
of the
come,
vice
fixation
fixation
in
anatomical
of good
in the
drawing
cent
a better
instances
and
of internal
consultant
23 per
with
patients,
internal
without
have
results
and
considered
of smoothness
for
were
‘precluded
method
statistical
own.
patients
there
clinical
‘
our
accounted
Group-B
size
open
should
M.D.
Box
Fourth
sample
be present
of our
outcome,
satisfying
surface
of
bias
in general
In discussing
in
and Shouse,
;
in Displaced
William
printed
advice
scale
that
clinical
riority
reference
not
F. G.
169-173,
In Table
the
anatomical
less
a
treatment
on
unintended
we found
with
with
itself.
open
9.8
times
of the
and
read
several
read:
in the article
between
should
cited
Role
J. Bone
errata
scores
based
any
a better
as representing
for
data
The
group
significantly
of treatment
our
treatment,
in this
was
recthen
small
and should
The
Ankle.
would
fracture.
management
score
method
fractures
which
the bibliography
LeRoy:
this
in anatomical
malleolar
number
to operative
should
of
and
of the
reduction.
VII the difference
for
fractures
finding
as adequate
management
his or her
for
scores,
each
orthopaedic
William
is
individual
surgeon.
A. Phillips,
M.D.
Box
To the
Editor:
Prospective.
tures’
the
Phillips
authors
of these
have
analysis.
that
to me
anatomical
approach.
For example.
in Group
result
true
The
small
Doesn’t
number
not
stract).
It merely
means
open
in Group
data
A had
odology,
patient
in Group
The
bias
other
may
remain
report
what
may
size
the authors
internal
provement
fixation
the
other
that
a larger
hand,
series
and
scores
with
has
the correct
been
shown
several
meth-
difference
difference
authors’
phrase.
local
to risk
wound
this
is one
place
sentence:
between
the
is that
I and
ligament
lateral
bias
one
open
will
reduction
significant
not
warranted.
of The
for The
was
not
larger.
Dr.
This
Weis
would
that
have
enabled
us to determine
if some
between
treatment
were
groups
it
is unfortunate
given
of the
statistically
and
is a double
1985)
the
both
of the
et al.,
for repairing
medial
error.
its
“Long-
by Snook
the technique
show
and
article,
Reconstruction
Jan.
this
does
Journal,
not
which
but,
as it has
diminish
the
admiration
has
given
me
even
nevertheless,
been
in the
arch
of the
foot
of the authors’
work
I wish
that
that
the
I have
honor
The
always
of publishing
Journal
could
always
past.
Luis
Gral.
Paz
M.
325
Buenos
Dr.
Snook
Japas,
M.D.
1834
Temperley
Aires,
Argentina
replies:
shows
the
foot,
which
quite
and
first
is obviously
1 have
Dr.
is. ofcourse,
navicular
for
in his criticism
bones
that
on the
the illustration
lateral
aspect
of the
incorrect.
no explanation
Japas
correct
cuneiform
for this
pointing
out
this
except
error
that
we missed
it, and
we thank
in illustration.
George
imNorthampton
But
even
a pulmonary
Editors
tvell.
B. Weis,
Jr.
,
7th
A. Snook,
6 Hatfield
M.D.
Street
Massachusetts
,
01060
itote:
We
ttisli
Meet
thank
to
cu/pa.
Dr.
l,i,n for
Japas
calliig
we are
is correct:
this
error
to our
at fault
as
atteiltiOfl.
California
M.D.
Street
92374
replies:
with
for
1-7,
to explain
ankle
This
in the
Operation
of The
its contents
Journal.
of my articles,
To the
editorial
agree
the fibula.
appears
(67-A:
volume
in both
problems?
Redlands.
We
48109
to wager
3055
Phillips
error
are meant
of the
American
perfect
outcome.
like
fatality,
E.
Dr.
to the
been
a serious
2. which
Of course.
when
size
in the clinical
I would
groups
power
sample
0n
‘
two
statistical
a highly
the authors’
happened
of the Ankle”
in Figures
Dr. Japas
a larger
not much
always
of the Chrisman-Snook
the
held
has
has
nevertheless,
Ligaments
that
What
Journal
to the severe
score:
limited
Michigan
as an abnormality
incongruities
to produce
difference
other
Results
Lateral
be perfect,
on the
in one
conclusion
that
prove
Term
a liability.
that
has
not
but.
one
treatment
based
become
of the
sc-ore.
closed
to the
same
be a real
the
which
according
demonstrated
and
enough
Editor:
The
editing
ab-
to be correct
anatomical
It is possible
the
raise
with
corresponding
these
because
and
Journal?
and
in the
in the result,
is allowed
the
is that
“
would
to
reduction
indicated
not
appear
incongruity
well
to use
is it a large
embolism.
arthritis
is clearly
in the anatomy
On
not
an asset
is small.
does
to be correct,
is overlap
unsubstantiated
sample
then,
had
joint
A. Thus.
an-
appears
closed
(as
of the patients
does
problem
in this
hand,
disprove
and
there
A second
to the
a precise
This
is not great
fixation
appear
since
closed
is due
even
unsatisfactory
conclusions
cent
arthritis
23 per cent
cases,
problem.
with
internal
does
However,
in these
the
severe
that
and
this
outcome!
To The
that
the entire
open
and
mean
the confidence
23 per
What
is that
category.
the
and
between
statistical
thing
accompanying
drawing
that
that
presented.
invalidates
clinical
Arbor,
54
Building
fixation
the
however.
simply
of patients
reduction
like
This.
level
Ann
Outpatient
that
patients.
prevent
statement
do not
0.05
Floor,
and the statistical
on the only
a good
older
internal
Fourth
Frac-
to me
or focus
in scores
this
and
presented
authors
at the
produce
B) does
The
results.
in the
reduction
A
‘
Ankle
It appears
size
the difference
(Group
is that
the
sample
A is significant
cannot
be especially
open
on the paper
of Severe
1985).
by the data
where
small
differences.
atomical
comments
Jan.
toward
that
the
treatment
anatomical
bias
the
is significant,
67-78.
is not justified
blame
some
of the Management
(67-A:
a strong
It seems
they
to offer
Study
et al.
fractures
results,
like
Randomized
by
‘
I would
us greater
other
that
statistical
differences
significant.
our
sample
power
that
We tried
we
‘
Editor:
‘Authors,
(66-A:
1327).
when
orthopaedic
The
enter
and
over
manufacture
to interpret
their
plex.
which
conflict
into
might
ofcourse
1 984
and
who
financial
have
and
THE JOURNAL
to is that
with
surgical
to the
Eisenhower’s
OF BONE
contains
by
‘ ,
which
may
arise
and
organizations
it does
hint
medical-industrial
reference
AND
an
Gartland
instruments
commercial
Although
by referring
Journal
Interests’
designed
marketing.
President
of The
of
referred
arrangements
be wrong
recalls
issue
Conflicts
of interest
surgeons
prostheses
arrangements
December
Readers.
size
found
The
JOINT
that
these
com-
to the U.S.
SURGERY
CORRESPONDENCE
military-industrial
are
complex,
wrong.
What
arrangements
have
in
from
a bias
which
garded
not
such
a financial
interest.
or organization
cannot
be pursued
interests.
been
codes.
is profit
good
for
necessary
common
and
that
United
may
States
in 83 per
cent
where
entrepreneurial
in America.
Matters
like
this
plex
rather
journal.
on the
practice
has always.
now,
President
Eisenhower’s
its effects
is applicable
the effect
systems.
effect
on
practice
about
to orthopaedic
take
some
this
concern
entrepreneurism,
comment
might
like
just
different
to appear
States.
the military-industrial
surgery,
at least
a
series
of a baseline
and
Choice
the
Anterior
Cruciate
Dameron
(62-A:
Severe
by
and
(66-A:
Dameron
is now
et al.
with
combined
ments
that
group,
the
used
were
and
States.
should
the
and
4000.
Australia
bad
results)’
in the
of all such
of medical
journals
therapeutic
trials’,
articles
clinical
do fulfill
the
Knee”
the
biased.
‘not
to
knees
collateral
was
group
ruptures
of their
anteriorcruciate
to their
study
Neifor
was
of the anterior
their
to
cruciate
series
did
not
injuries
injuries),
(the
the concept
series.
Group
trial,
discussed
clear
patients
such
were
how
of the
that
as
that
the
fact
control
on patients
influenced
included
group
should
the
a control
also
be
treated
in
choice
of
group.
as possible.
that
the
are to be compared
far
with
the same
patients
Neither
Furthermore,
in the
receive
of the
the
of JokI
interview
with
the
with
preconceived
their
cruciate
surgeon
treatment
discussed
series
anterior
based
this
series
in the
treatment
Bias
treatments
evaluation
the
and
series
to ensure,
and
of
Assessment
effects
liga-
no
approach
of Treaintent
with
series
et al
patient.
clear
If this
was
toward
the
bias
the
the
fulfilled
it is not
ruptures.
then
results
trial
reveals
a difference
are compared,
a statistical
recamount
same
this
pre-
who
did
by
the
done
conservative
were
probably
to rely
accepted
only
‘
effects
articles
sidered
to investigate
criteria’
was only
of treatment
both
and
the
Surgery
one group
the
statistical
scores
in the table
exclude
Results
the possible
the
in both
should
improved
possibility
the
is
variation.
statistical
some
evaluation
statements
variance
IV) that The
rising
without
that
articles.
the
were
should
made
be con-
be applied.
(Table
with
given
cited
of random
stated
between
evaluation
of random
However,
testing
were
influence
possibility
and Dameron
knee
values
trial.
that
is impossible.
where
McDaniel
for a con-
therapeutic
treatments
to consider
As there
be
Results
controlled
of the two
indispensable
control
should
advised
it is my purpose
generally
bias.
a control
cruciate
Psvchologic-al
themselves,
treatment
was
there
well
the observed
Because
of confidence.
final
conservative
in
are
included
the purpose
treatment,
Neither
the two
authors
injuries.
readers
et al.
since
of the conservative
medial
conservative
in
this
observer
and
that
Control
It is not
(1
If the
Although
the
of controlled
two
of
in twenty-eight
and
treated
selected
anterior
therapeutic
methods.
requisite.
by McDaniel
purpose
the results
conservatively.
treatment
authors’
cruciate
that
the
invalid,
effect
isolated
unrecognized
of the
practice.
amount
‘.
about
anterior
ofthe
article
in favor
the
and
Treatment
with
The
as evidence
statistics
of the
dealt
were
represents
authors
purposes.
an alternative
Both
Prevention
of
by McDaniel
Ligaments
1984)
although
Ruptures
“Non-Operative
injuries
the
of all untreated
be applied
controlled
receive
treatment
Terrace
‘
JokI
stated
sample
of Treatment
recorded.
F.R.A.C.S.
‘Untreated
Study’
ruptures.
cited
concluded
initial
Since
1980)
June
(or
treated
authors
on reports
trolled
results
lesions
as the
if these
widely
presented
‘
and AnteriorCruciate
ruptures.
good
JokI
July
cruciate-ligament
of these
demonstrate
Journal,
A Follow-up
741-744,
of anterior
treatment
in The
Ligament.
to the Medial
et al.
treatment
articles
696-705,
Injuries
JokI
Two
of all knee
how
placebo
of untreated
ofonly
of enthusiasm
Editor:
series
are usually
comparative
cannot
In any
ommends
the
criteria
present
as
be of
effects.
‘
It is necessary
To
rejection
signs
may
study.
nor
Dameron
future
consisted
Perhaps
Wickham
Brisbane
and
that
in the United
Chambers.
the
number
includes
Dameron
‘baseline’
‘
for
in an
complex
F.R.C.S.(Eng.),
Ballow
the
that
unclear
group
also
‘
of a random
private
L. C. Lahz,
a control
and
McDaniel
establish
ligament
note.
John
total
for their
of treatment
com-
in a country
United
knees
response’
McDaniel
a
and that this complex
in the
of the
‘
stated
in the
restraint.
and
comprehensive
However,
simply
It is thus
without
comparison
are
of the medical-industrial
is causing
supported
a prejudicial
in Australia
for an editorial
that
of surgery
up until
having
We
unusual
It suggests
fraction’
or developed
of symptoms
is very
is not
observed
of the meniscal
description
patients.
authors
injured
of
‘treatment
ther
aims
profession.
are
the
the
sign
preoperatively
of the removal
procedure
practice.
Trials
.
entre-
of the main
professional
series,
of future
and
present
patient)
anterior-drawer
Rczndo,ni:atio,i
professional
fee in the legal
selection
minority
has
is an overtly
one
et al.
(in an anesthetized
positive
because
treatment
private
if the
was
perhaps
Jokl
‘a small
‘
their
of medicine
British
in which
only
arthrotomy
patients’
the conflict,
there
given,
Avoid-
his
in the practice
adopted
for
not
Such
practice.
and
use
index
of the knees
as of the
a
of which
others.
well
the
it is unclear
period.
consist
It is therefore
is
Thus,
is
when
or some
of the
so removes
is. a system
of interest
there.
American
after
recorded.
follow-up
be re-
exists
for good
have
is the contingency
acceptable
conflict
one
principle
Such
of which
immediately
prostheses
would
practitioner
as if doing
countries
that
that
some
a medical
them
system:
and
of interest
the objectivity
its practitioners.
example
says
A conflict
affecting
in the
medical
editorial
as a fundamental
It is different
they
of these
a contributor
arrangements.
of interests,
as in most
preneurial
secret
a variety
publicizing
that
In the
so.
between
regarded
Australia,
in
with
that
instruments
adversely
conflicts
not just
always
has
without
interfere
such
is not
the view
knowledge
be unaware
just
The
This
not take
involving
not
in Australia.
term.
does
is to withhold
they
results
person
of
lest
reporting
as wrong
ance
editorial
is wrong
arrangements,
a precise
conflicts
say
readers
when
he has
Any
this
it does
1305
thigh
any measure
recorded
Hospital
for Special
circumference.
As
of variation.
differences
one
ensued
by
the
cannot
random
variation.
Selection
of Patients
The
JokI
therapeutic
trial
trapolate
the experience
patients.
For
this
gained
purpose,
rejection
from
the
the
must
form
trial
only
trial
serves
from
its purpose
the patients
the criteria
must
be well
a random
if it is possible
in the trial
for entry
defined;
sample
into
furthermore,
of all
future
that the probability
I by pure chance
as well
the
patients
return
to other.
the trial
fulfilling
et al.
to cxas for
patients
the
in
entry
stated
to preinjury
(Table
I) that
non-athletes
recreational
sports.
Statistical
had
of getting
as great a difference
is 0.33,
and thus the difference
insignificant
by usual
non-athletes
participated
statistical
standards.
poorest
sports
of
shows
shown
in Table
be considered
it is unclear
before
rate
however,
as that
would
(Besides,
in recreational
the
testing,
the
how
many
injury.)
criteria.
The
so on)
description
it is impossible
of all knees
operation
the
VOL.
of preoperative
is completely
lacking
to know
at follow-up
or if they
clinical
67-A,
status
NO.
if the
symptoms
examination
developed
of the
8.
symptoms
in the McDaniel
OCTOBER
during
knees
that
were
the
in terms
985
(such
and
as giving-way
Dameron
were
already
follow-up
of anterior
series
reported
present
period.
stability
the index
Furthermore,
before
The
thus
in 94 per cent
before
Discussion
and
and
uisites
servative
orthopaedic
and
treatment
two
for
reviewed
articles
controlled
treatment
textbooks
of knee
of
do not
fulfill
any
of the
trials.
Although
anterior
cruciate
injuries
were
clearly
reports
about
the
several
ligament
years
injuries
ago,
are
very
scarce
the
necessary
therapeutic
merits
in the
prereq-
of the
con-
stated
conservative
modern
ortho-
in
1306
CORRESPON
paedic
literature.
of knee
341
My
ligament
reports
dealing
the conservative
with
the conservative
I found
sten
et al. with
(not
cruciate
that
reports
there
studies
both
registered
difference
treatment
cruciate
reflects
therapeutic
was
The
between
of that
the groups
(forty-one
muscle
a randomized
authors
treated
patients)
strength
study
by Oden-
that
could
inclusion
(forty-
regard
months
injury
is not
On
informed
out
two
the
is surprising,
a life-endangering
relationship
and
The
other
second
merits
of con-
as the untreated
condition.
consent
null
be able
treatment
patient
The
in surgical
pertinent
scarcity
controlled
treatment
problem
relates
trial
‘the
‘
had
hand
the patient
study
flexed
to be spun
advice
out
clinical
Dr.
our
issue
of informed
and
appropriate
patient
the operation
at the
organization
same
point,
is randomized
is unnecessary
time
In a
conservative
starting
who
consent.
treat-
the
surgeon
used
with
still
explaining
persuade
specific
all risks
connected
that
that
life of surgical
it is ethically
therapeutic
trials
treatments
and
practice
it is difficult
permissible
that
and
it is unethical
of unproved
necessary
a natural
,
to assist
in the
MAGNUS;
GILLQuIsT,
Dameron
HAMBERG,
PER;
JAN: Treatment
and
Dr.
McDaniel
We
feel
to endorse
that
or
we
must
condemn
anterior-drawer
of the anterior
designed
been
to learn
injured.
in the
there
cruciate
We
would
be
ligament.
what
happens
were
concerned
literature
that
once
rapid
and
that
15 Boras,
our
Our
Sweden
1.
(without
that
after
not
for
patients
there
progressive
3.
4.
Jokl
ours
was
experiment.
It would
to age,
sex,
history,
and
so on.
scoping
each
of the
cruciate
ligament
a retrospective
study
have
been
size,
general
We
would
100 paired
in one-half
and
with
anterior
is either
ideal
individuals
to have
individuals,
of the
We
to pair
ligamentous
like
study.
like
letter
study
ligament
persons,
laxity,
our
that
known
We
transecting
and
anterior
of
vative
efficacy
the
knee
cruciate
had
suggested
treatment
such
of
treatment
accumulated
had a torn
hoped
that
this
anterior
could
be
their series
of persons
had been treated
by a
ligaments
or worse
suggests
than
that
specific
such
methods
B. Dameron,
Jr.
J. McDaniel,
Jr.
M.D.
,
,
Orthopaedic
North
J. S.: CONRAD,
Anterior
M.D.
Clinic
Box
10707
Carolina
WAYNE:
Ligament
Cruciate
,
therapeutic
with
normal
knees
United
activity
level,
family
the
arthro-
initiating
anterior
with
the
present
Many
27605
and KALEN.
Instability
in
trial
States
colleagues
is that,
versus
injuries
advocated
problem
different
population.
such
considerations,
study to collect
may
be cited
both
and finally
a statistically
by
surgical
the
this
What
knowledge,
surgical
no
treatment
raised
of
the question
with
whole
issue
approaches
These
in other
concerns,
to the patient
the
to our
compared
as
conserwas
the
to the anterior
study
as to the difficulty
degree
concerning
ofthe
end-results
interventions.
procedure.
medical-legal
a study
This
and a comparative
surgical
for a surgical
to some
raised
in many
co-authors
is controversial.
treatments
suggested
knee,
injuries
is available.
surgical
that
my
knowledge
of conservative
suggested
and
orthopaedic
points
me and
of our
trial
Another
factors
excellent
stimulated
cruciate
ligament-deficient
the
several
that
of anterior
many
of the many
a prospective
raises
impetus
The
of the
the various
short-
Surin
cruciate-ligament
treatment.
pesbeen
interfering
and
value
had
study,
study.
to the
undue
the normal
not
ever
we had
to have
cruciate
better
in TORG.
initial
treatment
therapeutic
had
a double-blind
Dr.
the
us
was
of
by
controlled
realized
to have
the knee
replies:
concerned
ligament
deterioration
would
(with
to compare
the evidence
of events
Diagnosis
summarize
from
of a retrospective
patient
the Athlete.
Am. J. Sports
Med.
4: 84-93,
1976.
BOHR,
H. : Experimental
Osteoarthritis
in the Rabbit
Knee Joint.
Acta
Orthop.
Scandinavica.
47: 558-565.
1976.
FEAGIN,
J. A. , JR. , and CURL,
W. W.: Isolated
Tear of the Anterior
Cruciate
Ligament:
5-Year
Follow-up
Study.
Am. J. Sports
Med. , 4:
95-100, 1976.
MARSHALL,
J. L. ; RUBIN,
R. M. : WANG,
J. B. : FETTO,
J. F. : and
ARNOCZKY,
S. P. : The Anterior
Cruciate
Ligament.
The Diagnosis
and
Treatment
of Its Injuries
and Their
Serious
Prognostic
Implications.
Orthop.
Rev. , 7: 35-46.
Oct.
1978.
Dr.
designed
follow-up
cruciate
that
‘
No
non-operative
We did not wish
of untreated
Clinical
The
the cruciate
perhaps
anterior
is
Blackwell
joint’.
necessity,
sign
our having
versus
or so earlier.
F. L.: Cited
ALLMAN.
VICKI:
2.
Follow-up
was
retrospective
to knees
the
paper
of treatment
that
M.D.
Hospital
Box 850
to initiate
type
knee.
P.O.
NORDIN.
MARKETTA:
LYSHOLM,
of the Acute
Torn
Anterior
Cru-
again
specific
but
of persons
of the knee’
of the
intro-
reply:
repeat
any
we weren’t
so be it.
appropriate
in regard
derangement
Raleigh,
Surin,
a history
arthrotomy.
operative
to give
the knee
gave
sample
Raleigh
ways
Of
surmised
of anterior
began,
a random
the
1963
when
stability,
to carry
ciate Ligament.
A Randomized
Study
with a Short-Term
[abstract].
Acta Orthop.
Scandinavica,
55: 474, 1984.
WULFF,
H. R. : Rational
Diagnosis
and Treatment.
Oxford,
Scientific.
1976.
comings
have
was
diagnosis
project
W.
,
ODENSTEN,
JACK; and
torn
index
study
in knee
arthrotomy
to the fifty persons
sequence
of treatment.
DUDLEY,
H. A. F. : Informed
Consent
in Surgical
Trials.
British
Med.
J. 289: 937-938,
1984.
MCDANIEL,
W. J. and DAMERON.
T. B.: Correspondence.
J. Bone
and Joint Surg.,
63-A:
333, Feb.
1981.
MAXWELL,
C. : Clinical
Trials
Protocol.
A Primer
for Clinical
Trials.
Sutton,
Stuart
Phillips,
1969.
simism
internal
merit.
S-50l
has
from
to follow
Central
was
our
some
(between
All patients
Thomas
in the real
of Wulff
of new
rupture
were
our
patients
the
known
been
method.
If the study
the
When
‘
an
in the knee
arthrotomy
meniscus.
positive
ten years
had
of open
meniscus
to the
wished
of
of the
as a baseline
for others
who wished
to report
traumatic
anterior
cruciate
deficiencies
who
to the surgical
and
ligament
study
other
structures
shortcoming
in our
ligaments.
had happened
or capsular
All
of
compared
We only
of what
have
to require
and others
cruciate
modalities.
to distinguish
prior
paper
well
A
suggestive
had a significantly
Surin
it) that
may
patients
enough
90 degrees)
cruciate
operative
is the
on,
classic
inability
methods.
to the
to the
an
Valdemar
Dr.
symptoms
there
of the
All of our
symptomatic
stated.
or both.
have
time.
any
for a torn
importance
at this
had
an operation.
the
5.
matter.
were
problem.
invitation
to the
to voice
comparing
hypothesis
perhaps
It seems
4.
who
usually
of the
country
who
at the time
or giving-way,
convinced
another
to this
on the one
than
accustomed
opposite
to be operated
duction
rather
it difficult
to explain
that
such
factors
the patient:
surgeons
find
therapeutic
if the
should
with
a decision
hand,
two
controlled
explored.
made
physical
then
patients
menisci.
included
history,
would
all
evident.
were
we
data.
ligamentous
torn
with
basis,
in this
as we
with
tear
torn anterior
practice
the
who
was being
the anterior
wheel”.
the
between
with
assessing
injury
with
pointed
advice
surgical
1973)
feasible
clinically
of patients
individuals
objective
eliminated
of other
cruciate-ligament
to running
after
and
not
with
but,
tearing
the
on a yearly
not
we
injury
were
in the
recently
roulette
ment,
trials
cruciate
the problems
personal
on the
therapeutic
of anterior
is the doctor’s
seeks
3.
not
are
study.
incomplete
study
operatively
with
nineteen
trial
follow
study
studies
In our
trials.
Dudley
2.
Such
treatments
therapeutic
then
arthroscopy
authenticated
the operative
of the controlled
in Medline)
of controlled
anterior
.
ideal
of catching
lack
probably
I
with
could
and
ligamentous
follow-up.
and
If we
examination,
dealing
to compare
others.
were
injury.
servative
of
twelve
In nine
the criteria
short-term
ability
The
One
only
on the treatment
revealed
was the purpose
and conservatively
and jumping
and
injuries.
of them
fulfilling
find any significant
patients)
1984
treatment.
report
that
for articles
through
of these
but in none
only
Medline
1977
the surgical
treatment
applied,
four
through
from
with
were
The
search
injuries
DENCE
countries,
potential
and
a controlled
specifically
the
organizing
of cases.
OF BONE
AND
in the
heterogeneity
increased
to a third-party
requirement
of
significant
number
THE JOURNAL
of initiating
include,
of
expense
payer.
a multicenter
This is not
JOINT
of
ethical
SURGERY
to
I 307
CORRESPONDENCE
say
that
a controlled
paedic
treatment
therapeutic
procedure.
for the introduction
of surgical
before
the
surgery
should
raises
afforded
give
logical
treatment
of the
final
in the
little
outcome
to other
of musculoskeletal
been
described
disorders.
That
A Case
another
with
our
specifically
study,
trial.
in view
we
studies
address
felt
of the
that
whose
justifying
our
knee.
we
did
the
that
significant
value.
criteria
were
of specific
the
numbers
of medial
not
and
a controlled
results
were
also
associated
were
not
stress
examination
taken
our
to give
for
study,
our
the
knee
was
because
with
this
in
that
injuries
to
it
and
suggestion
for
but difficult
unless
complete
consider
past
neglect
our
study
and
future
The
problem
done
by one
that
that
injuries
Dr.
criteria
Our
can-
We
how
knee.
injuries,
do feel
diagnosis
injuries
to
more
approach
again
and
that
until
and
the
did
are
it up to the
injury
and
the associated
to the
after
tremity
at four
data
rec-
problem
knee.
of
Stern
months
can
should
be obtained
that
make
from
the issues
us conscious
studies
that
in a controlled
raised
do not
on
New
NO.
for
The
tibia
very
represent
8. OCTOBER
1985
Haven
,
and
tumor
would
not
not speculate
history
as outlined
E. Stem,
M.D.
Park
York,
authors
have
well
have
girl
previously
Barta
deformity
at the age
speculating
Avenue
N.Y.
10021
to is that
other
that
our
birth
ma
have
was
unique
predilection
the
during
lesion
embryonal
case
deformity
congenital
of the
recognized
bones,
and
case
supports
a local
the
perfect
Jokl,
M.D.
60 Temple
Street
06510
3.
with
that
Stern
at birth.
in very
young
I still
was
more
than
feel
noted
at
fifty
variable
course
of regression
Bergstrand’s
disturbance
years,
as a disease
original
in the
con-
formation
M.
of
Szabo,
of California
X Street.
,
,
M.D.
at Davis
Room
California
BERGSTRAND,
HILDING:
Uber eine eigenartige,
wahrscheinlich
nicht
beschriebene
osteoblastische
Krankheit
in den langen
der Hand und des Fusses.
Acta Radiol.,
11: 597-613,
1930.
HABERMANN,
E. T. and STERN,
R. E.: Osteoid-Osteoma
of
in an Eight-Month-Old
Boy. J. Bone and Joint Surg.
56-A:
April
1974.
PONSETI.
IGNACIO,
and BARTA,
C. K. : Osteoid
Osteoma.
J.
Joint Surg.
29: 767-776,
July 1947.
,
of the
Dr.
however,
4301
2.
that
observed
Robert
.
made
problem
by an osteoid-osteoma.
University
I
in a
life.
to
are well
ankle
classification
for certain
through
The
an
patients
for
its etiology.
A congenital
arises
Barta.
have
was
deformity
to be caused
been
and
of the
in origin;
and
fibula
to
was
although
of the
of osteoid-osteomas
because
has
noted
of the
the osseous
birth,
no mention
in both
ex-
deformity
Habermann
part
Part
crying
lower
that
since
on by Ponseti
either.
skeletal
regarding
right
report.
first
attention.
a physical
distal
however,
demonstrated
questions
the
have
In their
was
literature
been
osteoid-osteoma
unanswered.
that
obvious
in the
subsequently
fundamental
process,
also
patient
and
no
cases
to my
and frequent
present
reported
actually
etiology
article
did not conclude
been
in the
in this
on a congenital
patients
cept
etiology
not
been.
of ten months;
congenital
are
did
to an osteoid-osteoma
Ponseti
this
in moving
child
The
and
involved
trial.
Connecticut
been
the
the baby
of irritability
may
patient
of
bringing
symptoms
months.
and
how
Sum
problems
therapeutic
after
the
to the
have
‘colicky
‘
We did
with
for knee
treatment
by Dr.
of the
them
may
was
that
months.
Sacramento,
information
only
baby
noticed
by difficulty
old.
patient’s
referred
Stern
fourteen-month-old
bone
In treating
potential
available
led
that
immediately
but certainly
to have
followed
that it may
remain
of the fence
the
birth.
in their
Although
own
Peter
67-A,
from
noted
the age ofeight
lesion
that
their
of conservative
are
sta-
of papers
side
with
ligament
data
suggest
to form
the other
a severe
to err on the side
the
as the age of four
to Dr.
was
shortly
There
of knowledge
number
from
article
been.
grateful
patient
referred
musculonot suggest
raw
state
approached
way
of ligamen-
the
readers
the overwhelming
not
treatment
At the present
convincing
was
efficacious
we did
disruption
more
we
injury.
of a specific
presented
a view
to emphasize
certainly
in interpreting
VOL.
I am
I believe
with
interview
most
however,
trial,
paper,
the grandmother
this injury.
I wish
taken,
be best
harm
we leave
with
is the
as an osteoid-
replies:
possible
concerning
numbers
I suppose
for comparison
‘
evaluation
regimens
are based.
be
K.).
paper,
to the orthopaedist
treat
it may
no
The
that,
cruciate-ligament
instability,
(N.
would
no treatment
for the cited
final
therapeutic
opinions
study
in which
advocated.
trial
of our
intervention,
be of value
to appropriately
anterior
study
treatment
in our study
surgical
well
other
for our
to the
ommending
may
S:abo
Their
documentation
the initial
group’
The
therapeutic
a controlled
knee
opinions.
of the
In defense
the opinions
concerning
data
most
justification
which
do
and
taken.
our
of a lesion
New
injuries.
cruciate
1974),
inclusion
exclusion
in our
were
‘control
‘
intervention
is well
a controlled
group
joint
a
of
statistically
potential
anterior
Boy.
April
and diagnosed
disappeared
lesion,
633-636,
an
old.
no report
this
of
in 1974.
in an Eight-Month-Old
months
in our
and
leg as early
have
excised
case
Journal
910
many
a population
injured
on surgical
of bias
it represented
tous
of the
dysfunction.
tistical
a control
as representing
studies
this
skeletal
of
it included
of the authors
I agree
to study
use
birth,
was
in The
(56-A:
oversight
been
a congenital
well
until
The
stated
Stern
that
in a fourteen-
Richard
the knee.
possible,
was
In addition,
that
was
may
has
As
from
authors’
‘there
and
eight
tibula
Os-
1947)
reported
appeared
June
“Osteoid
July
being
the
of inadequate
and
to ours
ligament
that
to substantiate
disruption
excised.
opinions.
enough
with
‘ .
the
‘
that
was
of the
to us for evaluation,
indicated
study
congenital’
kick
similar
for
great
retrospective
collateral-ligament
available
that
‘
baby
that
conclusion
was
of the tibia
Barta,
youngest
of the Tibia
Congenital
815-816,
767-776,
part
the
which
by Habermann
the
I think
other
,
a lesion
therapeutic
to our paper,
and
(29:
of the distal
to be
“Possible
(67-A:
Ponseti
in 1947
this
Smith,
Report”
by
Journal
“Osteoid-Osteoma
when
irritable’
with
report
found
prior
Report”
concerning
of ligamentous
of patients
We
Surin
as a comparison
justification
in detail.
for inclusion
value
of
were
commonly
via radiographic
in initiating
of cases
selection
in this
by Dr.
for the treatment
number
described
raised
have
statistical
In the
problem
didates
assessment
any
entities
greatest
for
small
attempt
conscious
cited
may
intervention
With
not
factors
paper
criteria
surgical
the
the questions
We
and
A Case
the
in The
girl.
osteoma
surgical
by Szabo
an osteoid-osteoma
described
procedures.
To
published
article,
itself,
or alternate
article
a Phalanx.
mention
osteoid-osteoma
the results
are a summary
compared
regimens
,
not
month-old
ther-
with
procedures
regimen
treatment
done,
comparison
surgical
treatment
potential
has
a pro-
procedure.
The
of
did
teoma”
of orthopaedic
surgical
the
most
of such
1985),
study
as an initial
use
trial
To the Editor:
Osteoid-Osteoma
to the evaluation
field
a new
an ortho-
to the approval
applied
general
concerning
of a certain
but not in relation
the
treatment
At best,
prior
of us in the
therapeutic
information
regimen.
been
for
all
applying
controlled
to evaluate
to my knowledge
that
before
feasible
has
advocacy
or drug
a supervised
and
rarely
points
consider
modality,
Unless
and
Sum
is not
it is the standard
drug.
although
introduction
Dr.
apeutic
of a new
procedures.
cedure.
trial
Certainly
211
95817
bisher
Knochen
the Tibia
633-636,
Bone
and
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