Tibial plateau fractures. A comparison of conservative and surgical treatment.

We evaluated the long-term results of 109 tibial plateau fractures, 61 treated by skeletal traction and early knee movement and 48 treated by surgery, at an average follow-up of 70 months. The functional results were much the same, though meniscectomy had been performed in almost half of the surgical patients. Time in bed and duration of hospital stay were clearly shorter after surgery (p less than 0.0001). We concluded that conservative management is a valid alternative to surgery, but should probably be reserved for cases where operation is undesirable. Future studies should compare surgery without meniscectomy and conservative treatment using cast braces to reduce the time in traction.

Magnetic resonance imaging in the evaluation of sequelae after tibial plateau fractures.

Nine knees with persistent radiographic depression of the articular surface after tibial plateau fractures treated by traction and early knee motion were examined using magnetic resonance imaging (MRI). The MRI examinations demonstrated that the radiographic bone defects were filled up with different tissues, which we interpreted as cartilage, fibrous tissue and synovial plica. The type of tissue in the bone defect did not seem to affect the functional capabilities of the knee. However, a demonstrable thin cover of tissue, with the signal-intensity of cartilage, over the defect, seemed to be associated with an excellent functional result.

Prevention of thromboembolism following elective hip surgery. The value of regional anesthesia and graded compression stockings.

Ninety-eight patients scheduled for elective hip arthroplasty receiving either general or regional anesthesia and graded compression stockings as the only thromboprophylactic treatment were screened for postoperative deep-venous thrombosis with 99mTc-plasmin scintimetry. The diagnosis of deep-venous thrombosis was established by phlebography and the diagnosis of pulmonary embolism by pulmonary perfusion and ventilation scintigraphy. Of 65 patients surgically treated under general anesthesia, 20 (31%) developed deep-venous thrombosis and six developed pulmonary embolism. Of 33 patients surgically treated using regional anesthesia, three (9%) developed deep-venous thrombosis and one developed a pulmonary embolus. The number of patients developing deep-venous thrombosis was significantly lower in the group receiving regional anesthesia compared with the group receiving general anesthesia. The results indicate the beneficial effects on the incidence of postoperative thromboembolic complications following elective hip surgery from the use of regional anesthesia and graded compression stockings.

Prevention of deep venous thrombosis following total hip replacement, using epidural analgesia.

Fifty-five patients undergoing total hip replacement using epidural analgesia were allocated to the combination of low dose heparin and dihydroergotamine (5.000 IU heparin and 0.5 mg dihydroergotamine given subcutaneously every twelve hours) (n = 27) or to placebo (n = 28). All patients wore thigh-length graded compression stockings. The patients were screened for deep venous thrombosis by means of the 99mTc-plasmin test and the diagnosis of deep-vein thrombosis was confirmed by ascending phlebography. Three patients in each group developed unilateral deep-venous thrombosis. One patient in each group developed non-fatal pulmonary embolism.

Contact thermography as a screening test for deep venous thrombosis following major hip surgery.

Contact thermography is a non-invasive, easily handled, and inexpensive investigation for the diagnosis of deep venous thrombosis (DVT) in the lower limbs. In this study 56 patients with total hip replacement were screened for DVT by contact thermography, using bilateral ascending phlebography as reference procedure. Examinations were performed on the seventh postoperative day. All thermograms were evaluated blindly and independently at the end of the study. Phlebography revealed unilateral DVT in six patients. Only two had corresponding findings at thermography, giving four false negative results. Moreover, 14 false positive thermograms were found. Based on the number of legs investigated, the nosographic sensitivity and specificity thus were 33 and 87 per cent, respectively. It is concluded that contact thermography is of no value as a screening test for DVT following major hip surgery.

Conventional radiographic examination in the evaluation of sequelae after tibial plateau fractures.

Seventy patients with 72 conservatively treated tibial plateau fractures were re-examined after an average of 5 3/4 years. Among 55 fractured knees with a primary articular depression of 1-20 mm, the depression was still present radiographically in 47 knees. No correlation existed between the persistent radiographic depression and function of the knee. Moderate to severe osteoarthrosis was found in 10 knees; in five of these the osteoarthrosis was of clinical importance. More than 10 degrees of valgus/varus deformity was present in two knees. In two patients osteotomy had been performed to correct deformity. It is concluded that a persistent radiographic articular depression is of no clinical importance in tibial plateau fractures treated by conservative methods, which include early movement of the knee. The radiographic examination, however is, useful in the evaluation of valgus/varus deformity and osteoarthrosis.

Contact thermography, 99mTc-plasmin scintimetry and 99mTc-plasmin scintigraphy as screening methods for deep venous thrombosis following major hip surgery.

Fifty-six patients scheduled for total hip alloplasty were screened for deep venous thrombosis by means of 99mTc-plasmin scintimetry, 99mTc-plasmin scintigraphy and contact thermography. Investigations were performed on the seventh postoperative day, and a total of 112 legs were examined. Bilateral ascending phlebography was used as reference procedure, and the criteria for deep venous thrombosis were intraluminal filling defects at phlebography. Six patients developed unilateral deep venous thrombosis. All three screening procedures revealed many false positive and several false negative results. The nosographic sensitivity/specificity was 33%/75% for scintimetry, 50%/91% for scintigraphy and 33%/87% for contact thermography, respectively. It is concluded that all three tests are of no value as screening methods for deep venous thrombosis following major elective hip surgery.

Bleeding after hip arthroplasty not increased by heparin plus dihydroergotamine.

We measured the postoperative bleeding following total hip replacement when low-dose heparin plus dihydroergotamine was used for preventing postoperative deep-venous thrombosis. The patients were allocated by random numbers to either 5,000 IU heparin and 0.5 mg dihydroergotamine injected subcutaneously twice daily or to placebo injections. The mean postoperative bleeding in the anticoagulation group of 91 patients was 583 ml and in the placebo group of 103 patients 529 ml, i.e., there was no difference between the two groups.

Conservative or surgical treatment of acromioclavicular dislocation. A prospective, controlled, randomized study.

In a prospective, controlled, randomized study of acute acromioclavicular dislocations, we compared conservative and operative treatment (the Phemister procedure) with regard to the clinical results, complications, and social costs. Forty-one patients were operated on and forty-three patients were treated conservatively. Two patients who were operated on and three who were treated conservatively had to have the lateral extremity of the clavicle resected because of pain. The rehabilitation period was significantly shorter with non-operative treatment, and after thirteen months there was no difference in the clinical results. There were no serious postoperative complications, but about half of the patients who were operated on had problems with the metallic device, such as breakage or migration of the pins, or both, and six patients had a superficial infection. For most patients with total acromioclavicular dislocation we recommend conservative treatment with a sling until the patient is free of pain. Operation should be considered in thin patients who have a prominent lateral end of the clavicle, in those who do heavy work, and in patients whose daily work requires that the shoulder often be held in about 90 degrees of abduction and flexion.

Dihydroergotamine and mobilization after major orthopedic surgery.

The effects of dihydroergotamine (DHE) on the degree of mobilization and response to orthostatic stress after total hip arthroplasty were studied. In the mobilization study, 78 patients received DHE, 0.5 mg im, twice a day from the day of surgery until full mobilization was achieved. Eighty-four patients who received placebo served as controls. There was no significant difference in the time until the first day of mobilization or the degree of mobilization. In the orthostatic test condition, subgroups of 61 patients receiving placebo and 55 patients receiving DHE were subjected to orthostatic testing. There were no differences in cardiovascular response to bed rest or in orthostatic stress. We conclude that DHE does not stabilize the cardiovascular reaction to orthostatic stress, nor does it enhance mobilization in patients after total hip arthroplasty.