Femoral component fixation with and without intramedullary plug. A 6-year follow-up.

A total of 113 patients underwent a cemented total hip replacement (THR) operation involving femoral component fixation either without the use of a distal intramedullary plug (n = 57, group 1) or with the plug (n = 56, group 2). We studied the femoral component fixation radiographically at on average 6 years after THR. The cement coating was assessed as technically good in 86% and 95% of groups 1 and 2, respectively. There was radiographically diagnosable loosening of the femoral component at the follow-up in 25 cases in which stems were inserted without the intramedullary plug, and in 6 cases in those with the plug (P < 0.0008), and the mean subsidence of the femoral component was 5 mm in group 1 and 1.5 mm (P < 0.0003) in group 2, respectively. Osteolytic changes around the femoral component were noticed in both groups in equal numbers and with no statistical difference. The use of a distal intramedullary plug in the cementation of the femoral stem results in a better cement coating, reduces femoral component subsidence and ameliorates the loosening rates.

Acute injuries in soccer, ice hockey, volleyball, basketball, judo, and karate: analysis of national registry data.

OBJECTIVE: To determine the acute injury profile in each of six sports and compare the injury rates between the sports. DESIGN: Analysis of national sports injury insurance registry data. SETTING: Finland during 1987-91. SUBJECTS: 621,691 person years of exposure among participants in soccer, ice hockey, volleyball, basketball, judo, or karate. MAIN OUTCOME MEASURES: Acute sports injuries requiring medical treatment and reported to the insurance company on structured forms by the patients and their doctors. RESULTS: 54,186 sports injuries were recorded. Injury rates were low in athletes aged under 15, while 20-24 year olds had the highest rates. Differences in injury rates between the sports were minor in this adult age group. Overall injury rates were higher in sports entailing more frequent and powerful body contact. Each sport had a specific injury profile. Fractures and dental injuries were most common in ice hockey and karate and least frequent in volleyball. Knee injuries were the most common cause of permanent disability. CONCLUSIONS: Based on the defined injury profiles in the different sports it is recommended that sports specific preventive measures should be employed to decrease the number of violent contacts between athletes, including improved game rules supported by careful refereeing. To prevent dental injuries the wearing of mouth guards should be encouraged, especially in ice hockey, karate, and basketball.

Local immune inflammatory response to infected total hip and knee replacements.

We studied the tissue response for periprosthetic pseudosynovial tissue in seven patients with a purulent endoprosthetic infection and six patients with common prosthesis loosening, using specific monoclonal antibodies in avidin-biotin-peroxidase complex staining. In infected cases, proline 4-hydroxylase positive fibroblasts dominated the stroma of the vascularized periprosthetic connective tissue, whereas diffuse local infiltrations of mononuclear cells characterized the cellular histological overview. Local cellular response consisted of CD11b and MHC locus II antigen-positive immunoreactive monocytes/macrophages and of T lymphocytes, mostly of the CD4 subset. Only a few CD25-positive cells could be detected. The local cellular response in six patients with prosthesis loosening of nonbacterial origin was mild, showing a sparse perivascular infiltration of CD11b- and Ia-positive monocytes/macrophages and CD4/CD8-positive T lymphocytes in a proportion of 2:1. Only occasional CD15- or lactoferrin-positive neutrophils and CD25-positive lymphocytes could be detected. Our results from chronically infected joint replacements suggest that neutrophils, being virtually absent in the tissue compartment, do not contribute to pathological events in the "pseudojoint" cavity, whereas local tissue response consists of a mononuclear inflammatory cell reaction of a macrophage-dependent foreign-body type.

The role of overlength of the leg in aseptic loosening after total hip arthroplasty.

A study was done on the role of postoperative leg length inequality (LLI) in aseptic loosening after total hip arthroplasty (THA). Data on 405 McKee-Farrar hip replacements performed at the Invalid Foundation, Helsinki, Finland were available for the study. The mean lengthening of the operated leg was 0.8 cm after an average follow-up of 7.7 years. Of these hips, 63 (15.6%) subsequently underwent revision due to aseptic loosening of the prosthesis. Several risk factors were analysed using multivariate stepwise regression analysis to find factors which predispose patients to loosening: overlength of the operated limb proved to be the most important. Our conclusion is that overlengthening should be avoided by careful preoperative and intraoperative length measurements and proper selection of prostheses. If there is marked overlengthening of the replaced hip postoperatively, it should be corrected.

Inflammation of the subacromial bursa in chronic shoulder pain.

Subacromial bursal tissue was studied in 12 patients operated on for painful (10 patients with constant pain and 2 patients with pain on motion) rotator cuff tendinitis/impingement syndrome. The Neer acromioplasty technique was used. Six patients had moderate inflammatory changes and one had a slight inflammation. In three of the five remaining patients, the subacromial bursa did not show any signs of inflammatory involvement, but patients experienced pain at rest and at night, reflecting clinical inflammation in tissues other than the bursa. The two patients with pain only on strain did not show inflammation of the bursa. Immunohistochemical typing of the bursal tissue disclosed a typical chronic mononuclear cell infiltrate consisting mainly of CD2-positive T lymphocytes (50-80% of all inflammatory cells), accompanied by less frequent CD11b (C3bi receptor)-positive monocyte/macrophages (10-40%). The relative paucity of plasmablasts/plasma cells expressing PCA-1 suggests this to be an inflammatory rather than an immune response. Active involvement of some of the local cells is suggested to be the source of algogenic and hyperalgesic substances contributing to pain in chronic shoulder pain syndromes.

Immunoreactive neuropeptide nerves in ligamentous tissue in chronic shoulder pain.

Coracoacromial ligament and periligamentous fatty and loose connective tissue obtained during Neer's acromioplasty in patients with chronic painful rotator cuff tendinitis/impingement syndrome was studied for possible signs of inflammatory involvement and for the presence of neuropeptide-containing nerves, using routine histology and immunoperoxidase staining. No accumulations of inflammatory cells were found in the tissues studied. The dense ligamentous tissue proper was practically aneural, as was seen in staining for the generalized neuronal markers protein gene product 9.5 and synaptophysin. In contrast, the periligamentous fatty and loose connective tissue was innervated. Almost all nerves in such tissue contained C-flanking peptide of neuropeptide Y, whereas substance P, calcitonin gene-related peptide, and vasoactive intestinal peptide-containing nerves were not found at all or were extremely rare. This suggests that the coracoacromial ligament is not a target of irritative inflammation. In the periligamentary sheath, nerves containing markers for the C-type nociceptive pain fibers were practically absent and all local nerves were postganglionic sympathetic vaso-regulatory nerves.

Disc degeneration and angular movement of the lumbar spine: comparative study using plain and flexion-extension radiography and discography.

A study was made of the association between disc degeneration observed in plain radiographs, in discograms (Adams' classification), and instability expressed as abnormal angular movement of lumbar vertebrae. The series included 169 discs in 77 consecutive patients (42 men, 35 women) whose mean age was 34 (range 16-46) years. Discography was more sensitive than plain radiography in the diagnosis of disc degeneration was more common in men than in women (Chi square test, chi 2 = 9.88, p less than 0.05). An increase in disc degeneration was observed in lower lumbar segments (Chi square test, chi 2 = 48.63 p less than 0.001). However, no association between abnormal angular movement and discogram type was observed (Chi square test, chi 2 = 2.63, p less than 0.05). It seems that disc degeneration seldom results in abnormal angular movement and instability of the lumbar spine. Therefore, flexion-extension radiography may only have limited diagnostic value.

Total hip replacement after intertrochanteric osteotomy.

Forty-five hips were analyzed in 42 patients treated with total hip replacements (THR) after earlier intertrochanteric osteotomies. At time of osteotomy, the patients' mean age was 50 years (range: 14 to 65). Total hip replacement was performed at a mean interval of 11.9 years later (standard deviation: 7.7). Narrowing or closure of the medullary canal made insertion of the prosthesis stem difficult in 10 cases. After THR, the patients were followed for a mean of 6 years (range: 3 to 11). At follow up, the hips had a mean Mayo score of 81 (SD = 13) points (17 excellent, 12 good, 7 fair, 9 poor). The failure rate was 6.7%. Being overweight had an adverse effect on outcome. Intertrochanteric osteotomy may impair results after subsequent THR.

Ten-year results of operations for rheumatoid cervical spine disorders.

The outcome of operations performed on 38 patients for rheumatoid disorders of the cervical spine were analysed 10 or more years later. The mean age of the patients at the time of operation was 56 years (35 to 77); 32 had seropositive disease. The mean duration of the disease was 17 years (four to 36). Twenty-seven patients had painful anterior atlanto-axial subluxation (AAS), nine had subaxial subluxation alone and two had severe cranial subluxation of the odontoid, one also with subaxial subluxation. One patient died from postoperative staphylococcal septicaemia and another 18 died during the follow-up period. Patients with coincident cardiac or other diseases, and those with cranial subluxation of the odontoid of more than 3 mm had an increased mortality. Neither the patients' age nor the magnitude of AAS correlated with mortality. Of the 37 patients with occipitocervical pain, 30 were relieved and all the six patients with tetraparesis were improved. Of the 24 Gallie fusions only 12 were solidly united; patients with long-term cortisone treatment were more likely to develop pseudarthrosis. There was no correlation between clinical outcome and radiological result. Four patients had further operations to treat subluxation which developed below the fused segments.

Three cancellous bone screws versus a screw-angle plate in the treatment of Garden I and II fractures of the femoral neck.

A consecutive clinical series of 33 patients with either an undisplaced (Garden I) or minimally displaced (Garden II) femoral neck fracture was randomly divided into two operative protocols. Half of the fractures were treated with three cannulated cancellous bone screws, while the other half were treated with a standard screw-angle plate device. After a mean follow-up of 2 years, 4 patients had died, while 20 of the remaining 29 hips showed excellent or good, 3 fair and 6 poor functional results. The three-screw fixation seemed to yield more technical complications as compared to the screw-angle plate fixation. However, the differences in functional end-results were of no clear statistical significance. We conclude that the screw-angle plate device gives acceptable results in this group of fractures. The use of cannulated hip screws may be more advantageous in the treatment of dislocated femoral neck fractures, where the torsional strength of fracture fixation and femoral head viability are more critical.

Premedication and short term complications in iohexol discography.

In 52 patients 0.5-3.0 ml of iohexol, 180 mg/ml, was injected using lateral injection technique and fluoroscopy control. A total of 146 lumbar discs using local anaesthesia was injected. Two types of premedication were used; either diazepam alone or diazepam in combination with pethidine and glycopyrronium bromide. There was no difference in the discography injection pain between the groups (X2 = 0.774, P greater than 0.05]. During discography, some patients had nausea (2%), convulsions (4%), back pain (6%) and hypotension (10%), but no allergic reactions were seen. This suggests that these immediate reactions are more related to the procedure itself than to the non-ionic ratio 3.0 iohexol contrast medium. More troublesome iatrogenic complications were seen the day after the discography in the form of severe headache (10%) probably related to liquor leakage, and increasing low back pain (81%). The latter may be caused by local haematoma or chemical irritation from iohexol. Patients with no pain during injection had a relatively slight need for analgesics (Somer's D = -0.196, P less than 0.05).

A comparison between cemented and cementless implants in revision arthroplasty of the hip following resection arthroplasty.

Twenty patients underwent hip re-arthroplasty following resection arthroplasty due to former prosthetic infection, aseptic loosening, or TBC coxitis. In 9 cases Gentamycin-loaded cement was used. In 11 the re-arthroplasty was cementless. The overall results, evaluated by the Mayo and Harris scoring systems, were moderately good. Seventy-five per cent of patients reported relief from pain and improved hip function. However, in the previously infected cases significantly better results were found in the cementless group, while major complications such as deep infection, luxation, or loosening of the implant were mainly concentrated in the cementless re-arthroplasties following aseptic loosening and cemented re-arthroplasties following septic as well as aseptic failures.

Clinical relevance of discography combined with CT scanning. A study of 100 patients.

Two different classifications of discograms have been used in a prospective study of 279 injected discs in 100 patients. The five-stage classification of Adams, Dolan and Hutton (1986) showed increased degeneration in the lower lumbar discs and more degenerative changes in men than in women. Exact reproduction of the patient's pain on injection was more common in fissured or ruptured discs than in less degenerate discs, with 81% sensitivity and 64% specificity of the discogram for pain. The additional information obtained by comparing computerised tomography (CT) with discograms was minimal. Discography was found to be useful in the evaluation of chronic low back pain in patients whose ordinary CT scans, myelograms and flexion-extension radiographs were normal. In spondylolysis and spondylolisthesis, discography can disclose whether fusion needs to be extended above the lytic level, and it may show if the pain in patients who have had posterolateral fusion is discogenic. Thus, discography gives information which is useful in deciding whether to operate on patients with chronic low back pain.

Neuroimmunohistochemical analysis of peridiscal nociceptive neural elements.

Twenty-three perioperative tissue samples from lumbar disc operations on 11 patients were studied immunohistochemically using the sensitive avidin-biotin-peroxidase complex (ABC) method and specific heterologous antisera for the presence of neurofilament-positive neural elements containing nociceptive neuropeptides substance P (SP) and/or calcitonin gene-related peptide (CGRP). Histologically, neural elements were especially abundant in the posterior longitudinal ligament, there being also a few demonstrable nerves in the peripheral anulus fibrosus. These nerves often showed a co-localization of cytoskeletal neurofilaments together with SP and/or CGRP immunoreactivity. It is suggested that pressure and chemical irritation of nociceptive nerves dependent on degenerated discs excite sensory neural elements, especially in the posterior longitudinal ligament and possibly also in the peripheral parts of the anulus fibrosus, while the disc itself, at least if not penetrated by vascular granular tissue, is painless and neuroanatomically lacks a structural basis for pain perception.

Hip arthroplasty infection. Current concepts.

Due to systemic or local antibiotic treatment and other preventive procedures, the incidence of deep hip-prosthetic infections in Scandinavia is less than 1 percent, with the majority hematogenous. Coagulase-negative staphylococci and anaerobes are involved in more than half of the cases. The diagnosis is sometimes difficult; preoperative aspiration often gives misleading results; and granulocyte scanning usually adds valuable information. In deep infection the current strategy is to revise with a two-stage procedure. Revisions should be carried out at specialized centers with bacteriologic competence and sufficient experience with implants.

Fibroblasts in synovitis in rheumatoid arthritis but not in noninflammatory synovial tissue in meniscus lesions express the carboxyterminal domain of procollagen type I.

Synovial tissue (ST) sections from patients with rheumatoid arthritis (RA) and meniscus lesions were stained using monoclonal antibodies against the carboxyterminal domain of human type I procollagen (alpha-pC) in avidin-biotin-peroxidase complex (ABC) staining. This gave a good signal-noise ratio and identified some synovial B-type lining cells and stromal fibroblasts in inflammatory RA ST but not in noninflammatory ST from patients with meniscus lesions. The authors' findings provide immunohistochemical evidence that the local fibroblasts in inflammatory ST in RA are activated, probably as a result of various humoral mediators produced in situ (by inflammatory mononuclear cells) in RA but not in normal noninflammatory ST.

[Strategy in endoprosthesis infections]. / Strategie der Endoprotheseinfektionen.

Infection in total hip replacement, its definition, normal history and treatment are reviewed. A case with a two stage revision with the use of a cementless resection prosthesis is presented.

Severe frostbite of the upper extremities--a psychosocial problem mostly associated with alcohol abuse.

In the catchment area of Helsinki University Central Hospital (in total 16 surgical hospitals) amputation was performed on 9 patients with frostbite in the upper extremities during 1984-1985. The population during the study period in this area was 1.165,000 inhabitants, corresponding to 24% of the whole population in Finland. All 9 patients were male and the mean age was 49 years (range 31-75). All amputations performed were of the fingers, the third, fourth and fifth fingers most frequently affected. Alcohol was a marked etiologic or contributing factor in most of the frostbites. Two patients were chronic schizophrenics showing no signs of alcohol abuse, but the remaining 7 were either acutely or chronically alcohol intoxicated: 5 patients were chronic alcoholics, one was an alcohol abuser without a definite diagnosis of alcoholism, and one patient with no previous history of alcohol abuse was alcohol intoxicated. Based on the present study it is clear that, in addition to the cold winters in Finland, other factors contribute to severe frostbite. These include many psychosocial factors such as alcoholism or mental disease, unbalanced marital status, occupation handicap and lack of regular residence.