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Retained hardware embedded deep in soft tissues or overgrown with bone poses a challenge to the surgeon assigned to its removal. A prototype of a hand-held electromagnetic metal detector-locater was used to localize retained hardware. Stainless-steel pins, screws, plates, and staples were located in 21 consecutive hardware removal procedures in 19 pediatric patients. Time to find the hardware, length of incision, blood loss, tissue maceration, and operative time were minimized. This preliminary study suggests that a metal locater may be a valuable tool when retained hardware is not palpable or readily apparent.

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Thirty-eight percent of patients with internal skeletal fixation had indications for removal other than uncomplicated healing. Plates were removed (p = 0.023) routinely, however, because intramedullary rods and staples were likely to be subcutaneous and painful (p = 0.02). Complications included incomplete removal of the device (7%) and two postoperative fractures. Most complications had no known significant adverse effects on the patients. Operative time and blood loss were significantly increased when a tourniquet could not be used. We believe that the high percentage of other indications for metal removal and the low incidence of major complications support the practice of routine metal removal in this population.

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The detection of musculoskeletal sepsis, especially following joint replacement, continues to be a challenging problem. Often, even with invasive diagnostic evaluation, the diagnosis of infection remains uncertain. This is a report on the first 55 Indium-111 white blood cell (WBC) images performed in 39 patients for the evaluation of musculoskeletal sepsis. There were 40 negative and 15 positive Indium-111 WBC images. These were correlated with operative culture and tissue pathology, aspiration culture, and clinical findings. Thirty-eight images were performed for the evaluation of possible total joint sepsis (8 positive and 30 negative images); 17 for the evaluation of nonarthroplasty-related musculoskeletal sepsis (7 positive and 10 negative images). Overall, there were 13 true-positive, 39 true-negative, two false-positive, and one false-negative images. Indium-111 WBC imaging is a sensitive and specific means of evaluating musculoskeletal sepsis, especially following total joint replacement.

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Long bone fractures frequently cause limb swelling and joint stiffness, and the two effects are generally assumed to be related, an assumption long held but rarely tested. The authors investigated limb swelling and joint stiffness in rabbits with experimental 28-day healing fractures. Eleven control rabbits were treated with bilateral hind limb skeletal fixation and unilateral distal tibia fractures. Subsequent limb swelling occurred bilaterally, but it was significantly greater on the side fractured. All fractures healed. Ankles in both fractured and unfractured limbs became significantly stiffer, compared with preinjury values, but ankles in the fractured limbs became significantly stiffer than those in the unfractured control limbs. Air pressure of 10 mmHg above atmospheric pressure was applied for four days to newly fractured limbs in 11 additional rabbits. Pressurization reduced swelling but did not significantly affect ankle stiffness. In general, reduction in postfracture swelling by application of external pressure did not significantly affect adjacent joint stiffness.

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Giant cell tumor GCT of bone remains a difficult and challenging management problem because there are no absolute clinical, radiographic, or histologic parameters that accurately predict the tendency of any single lesion to recur or metastasize. Enneking's and Campanacci's radiographic classifications and surgical staging are helpful in planning the initial surgical treatment, because they have observed that a number of the active (Stage 2) lesions and most of the aggressive (Stage 3) lesions have a higher incidence of local recurrence when treated by curettage alone. The bad reputation of curettage and bone grafting is undeserved and arose because of the indiscriminate application of this technique to lesions irrespective of their surgical stage. The ideal aim in the management of GCT is to eradicate the tumor and still save the joint. Curettage, possibly with adjuvant chemical or thermal cauterization, and with bone grafting or polymethyl methacrylate instillation, maintains the structural integrity of the bone and allows for early function. Good results with these techniques when applied to Stage 1 and many Stage 2 lesions may be expected in 70%--80% of the cases. Repetitive freezes with liquid nitrogen, though resulting in a lower recurrence rate, carry with them a not insignificant risk of local complications, require prolonged bracing, and incur the risk of late fracture. When GCTs occur in expendable bones, en bloc resection is the treatment of choice. En bloc resection of major joints requires a facility with reconstruction techniques including the use of allografts, large autogenous grafts and fusion, or custom arthroplasty. These are technically difficult procedures with many early and late complications. Patients have restricted function, and may require prolonged bracing even when uncomplicated. These techniques are therefore reserved for the Stage 3 and selected Stage 2 lesions. Hand lesions have been ineffectively treated by curettage and grafting, and are best treated by early en bloc or ray resection. Multicentric lesions should be handled as individual primary tumors would be in those locations. Radiation therapy has its major role in the treatment of giant cell tumors of the spine and sacrum that are not amenable to complete surgical resection, though long-term sarcomatous change must be looked for. Because of the complex management problem this rare tumor presents, it is recommended that management of giant cell tumor of bone, including the biopsy, the definitive surgery, and the follow-up examination, be carried out by individuals and institutions familiar with this entity.

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Between September 1971 and May 1982, at the University of California at Los Angeles Medical Center, 821 total knee arthroplasties were performed in 604 patients, all of whom received perioperative antibiotics. Deep sepsis, proved by a positive culture of a specimen obtained by postoperative arthrocentesis, developed fourteen times in thirteen knees of twelve patients, an incidence of 1.71 per cent. In one of these patients, who had systemic lupus erythematosus and bilateral knee replacement, the right knee became infected with two distinct organisms on two different occasions (separated by ten months). The first infection was probably hematogenous while the second, developing after a dental procedure, definitely was. Over-all, five infections were hematogenous with an identified source and one other was suspected of having a hematogenous origin. The time from operation to the diagnosis of sepsis averaged 8.3 months over-all, but five of the fourteen infections were recognized less than two months after arthroplasty. For the six infections that were assumed to be hematogenous, the time from operation to the diagnosis of sepsis averaged 16.4 months. The major presenting symptom was pain in thirteen of the fourteen infections. The initial treatments of the fourteen infections consisted of intravenous antibiotics in all of them, primary removal of the prosthesis and so-called exchange arthroplasty after five days in one, removal of the prosthesis and fusion in one, arthrotomy and débridement in six, arthroscopic irrigation in three, and antibiotics alone in three (of which one was treated with an exchange arthroplasty after three weeks). At last follow-up, only four of the thirteen prostheses had been salvaged.(ABSTRACT TRUNCATED AT 250 WORDS)

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