[Tuberculous osteomyelitis in children--a problem of immigrants?]. / Tuberkuløs osteomyelitis hos børn--et indvandrerproblem?

The incidence of tuberculosis in Denmark has increased in recent years, owing to immigrants from, primarily, Somalia. Bone and joint TB are mainly seen in young immigrants and a case of tuberculous ostitis of the tarsal bones and surrounding soft tissue is described.

Decreasing incidence of major amputations in people with diabetes.

AIMS/HYPOTHESIS: To assess the results of the strategy used in avoiding major amputations in patients with diabetes mellitus. METHODS: A retrospective study for the years 1981 to 1995 in a central district hospital in Copenhagen with a catchment area population of about 178,000. RESULTS: There were 463 major leg amputations and the incidence decreased from 27.2 to 6.9/100,000 population (75%). The decrease in patients with Type I (insulin-dependent) diabetes mellitus was from 10.0 to 4.1 (59%) and in Type II (non-insulin-dependent) diabetes mellitus from 17.2 to 2.8/100,000 people (84%). Analysis showed that the diabetic population remained constant despite a considerable fall in the number of older people. During the study period infra-popliteal arterial bypass was introduced for the treatment of critical lower limb ischaemia and in diabetic patients the number of bypasses increased from zero to 13/100,000 population. The total number of revascularisation procedures in people with diabetes increased from 2.6 to 19.2/100,000 population. Moreover, a multidisciplinary diabetic foot clinic was established. CONCLUSION/INTERPRETATION: A 75% reduction in the incidence of major amputations coincided with a sevenfold increase in revascularization procedures and the establishment of a multidisciplinary diabetic foot clinic suggesting these measures are important in the prevention of diabetic leg amputations.

Patient compliance and effect of orthopaedic shoes.

Orthopaedic shoes are individually handmade after a prescription from an orthopaedic surgeon, hence relatively expensive. Bad compliance is mentioned in the literature but not investigated. In order to evaluate patient compliance and the effect of orthopaedic shoes, 85 patients who were prescribed orthopaedic shoes at the authors' department during a 3 year period received a questionnaire concerning relief of symptoms and daily use of the shoes. The answers from 74 patients were correlated to the prescription procedure and the degree of medical follow-up. Only 60 of 74 patients used their shoes. Some 51 patients had some benefit while 23 had no effect or even worse symptoms. Some patients even used their shoes despite no symptomatic relief. However, patients who felt they were well informed about the purpose and function of their shoes had more benefit than the rest. Only 12 patients of the 74 were checked by the orthopaedic surgeon after delivery of the shoes. In conclusion the authors believe there is a great need for information to be given to the patients about the functions and limitations of orthopaedic shoes and that every patient should be offered a control check-up by the surgeon. Further investigations of the effect of orthopaedic shoes should be carried out to optimise the use of these expensive devices.

Hypertrophic scars and keloids: a recurrent problem revisited.

Excess scarring caused by pathologically overabundant collagen deposition is a problem known by all surgeons. Such complications to wound healing known as hypertrophic scars and keloids might turn out aesthetically unacceptable to the patient and some scars might even cause anatomic dysfunction. Reviewing the literature in planning a strategy of treatment the surgeon encounters an overwhelming amount of hypotheses on the topic. There seems to be no absolutely effective treatment for hypertrophic scars and keloids and the number of treatment modalities illustrate the lack of understanding concerning this kind of pathologic scarhealing. Most studies have not been well controlled and have produced conflicting results. This review outlines the nature of hypertrophic scars and keloid. Based on a critical assessment of current treatment modalities some guidelines for the choice of treatment is proposed.

[Reduced frequency of amputation in diabetic patients]. / Amputationsfrekvens hos diabetikere reduceres.

The number of major amputations performed for vascular disease in Bispebjerbx Hospital, Copenhagen, has decreased from 122 to 29 per year during the period 1981 to 1994. In diabetic patients the frequency decreased from 25.5/100,000 to 5.5/100,000, i.e. a reduction of 78 percent, and in non diabetics it decreased from 42.2/100,000 to 14.6/100,000, i.e. a reduction of 65 percent. During the period vascular surgery has become a surgical specialty (1983), bypass to infra-popliteal arteries (from 1988) and graft surveillance by colour duplex scanning (from 1983) has become routine and in 1993 a diabetic foot center was established. Initial experience with a diabetic foot center in a vascular surgery unit is reported.

No effect of low power laser in lateral epicondylitis.

Thirty-six patients with lateral epicondylitis of the elbow (19 women, 17 men, median age 48 yrs) were treated either with active laser or placebo, 18 patients in each group. The active laser was a GA-AL-AS 30 mW/830 nm low power laser (LPL). The study design was double blind and randomized. The treatment session consisted of eight treatments, two per week. Patients were irradiated on tender points on the lateral epicondyle and in the forearm extensors. Output power was 3,6 J/point. A follow up was performed by telephone, 10 weeks after the last treatment. No difference between laser and placebo was found on lateral elbow pain (Mann Whitney test, 95% confidence limits). We conclude that low power laser offers no advantage over placebo in the treatment of musculoskeletal pain as lateral epicondylitis. Further studies with low power laser treatment of musculoskeletal pain seem useless.

Long-term results after surgical reduction cheiloplasty in patients with Melkersson-Rosenthal syndrome and cheilitis granulomatosa.

Cheilitis granulomatosa in patients with Melkersson-Rosenthal syndrome has proven difficult to treat, and various forms of symptomatic treatment of orofacial swellings have been used with varying success. To evaluate long-term results after surgical reduction cheiloplasty in patients suffering from persistent lip swellings, a follow-up study was performed on 13 patients after 16 years (median). The operations were performed after unsuccessful conservative treatment and regardless of disease activity. Pre- and postoperative medical histories were updated and a clinical examination evaluated the following criteria for a good result: symmetry of the lip, a normalized anterior projection, dimensional harmony between upper and lower lip, no disfiguring cicatrices, and no sensory disturbances. In spite of postoperative disease activity in 6 patients, all 13 patients were satisfied with the long-term result. Clinically, the results in 12 patients were considered good. We therefore recommend lip resection as described when a stationary swelling becomes associated with permanent aesthetic deformity or functional disturbances and conservative measures are unsuccessful.

[Development of carcinoma in chronic pressure sores in patients with spinal cord injuries]. / Udvikling af karcinom i kroniske tryksår hos rygmarvsskadede patienter.

Three cases are presented of squamous cell carcinoma arising from chronic pressure sores in spinal cord injury (SCI) patients. These pressure-sore carcinomas are characterised by a fulminant clinical course with a very high metastatic rate. Prevention of pressure sores and surgical management of chronic ulcers are the best means of preventing malignant changes. Admittance of paraplegic and tetraplegic patients with pressure sores to a SCI center is recommended.

Hypoxaemia after osteosynthesis of hip fractures.

Hypoxaemia may cause postoperative confusion after operations for hip fractures in elderly patients. Twenty-two consecutive patients, with a median age of 73 years, had fractures fixed with a sliding hip screw within 48 hours of admission. The incidence of hypoxaemia was investigated postoperatively using a pulse oximeter. We have demonstrated that this complication occurs frequently on the first day and severe hypoxaemia can be prevented by supplementary oxygen therapy. Our results support the hypothesis that postoperative confusion can be caused by hypoxaemia.

Aplasia of the anterior cruciate ligament with a compensating posterior cruciate ligament.

Aplasia of the anterior cruciate ligament is a rare condition and is usually associated with other abnormalities of the lower extremities. We report aplasia of the anterior cruciate ligament with a compensating posterior cruciate ligament in a 15-year-old boy.

Changes in C-reactive protein and erythrocyte sedimentation rate after hip fractures.

Serial measurements of C-reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR) were performed during the week after operation in 140 patients with hip fractures. There was no selection, and patients with minor or major complications before or after operation were included. In uncomplicated cases, the ESR was variably raised during the first week, whereas the CRP showed a distinct pattern with a rapid increase on the second day; it then decreased by the 7th day. In cases with early postoperative bronchopneumonia and deep wound infection, the CRP was high, but minor infections did not influence the usual levels. Complications had no effect on the ESR during the 1st week.

Low level laser treatment of chondromalacia patellae.

A randomized, double blind study of low level laser treatment of chondromalacia of the patella in 40 patients has been undertaken. Chondromalacia was established by arthroscopy and was related to subjective symptoms. Eight treatments were given during five weeks by a physiotherapist with the use of a GAAS pulsed laser, real or sham. Assessment of the location, quality and intensity of pain, and the influence on mood, gait, sleep, work, and sports was made before and after treatment including an eight to twelve week evaluation. No statistical difference was found between real and sham use of low level laser for the symptoms of chondromalacia of the patella.

Outcome in 282 lower extremity amputations. Knee salvage and survival.

Lower-extremity amputation for arterial insufficiency was performed in 282 cases ineligible for vascular surgery. In 203 cases (Group I), amputation was elective without previous vascular surgery. In 14 cases (Group II), amputation followed recent vascular reconstruction, and in 12 cases (Group III) amputation was performed after failed thromboembolectomy. In 53 cases (Group IV), amputation was done acutely, i.e., as a life-saving procedure because of septicemia. The results as regards both knee salvage and survival were much better in Groups I and II than in Groups III and IV. We conclude that knee salvage is poor and mortality high after acute amputations and after failed thrombembolectomy. These factors should be taken into account when comparing series from different centers.

Injury producing factors in sport parachuting.

On the basis of a study of the literature and a description of the parachute jump, the injury producing factors of civil parachuting is described. The majority of injury happens during landing; the assuming of a correct "prepare to land attitude" and the execution of a good parachute landing fall may prevent a great part of the injuries to the spine and the lower extremities. The factors mentioned are often correlated to ignorance, inexperience or to willful neglect of current regulations. A revision of the education of student parachuters and instructors in order to meet the same quality demands in all parachuting centres is proposed. Safer parachutes and a simplification of the parachute landing fall may also reduce the incidence of casualties.

Movements causing ankle fractures in parachuting.

The parachutist injured in a dramatic accident often describes the injury in an incomplete and biased way and evaluation of materials based solely upon subjective information of this kind can be misleading and of no value for recommendations. As the relation between the mechanical factors of the injury and the lesion in ankle fractures is well documented, an investigation of clinical, radiological and operative findings in 46 parachutists with ankle fractures was conducted. Classification was possible in 44 of 46 fractures. The description of the cause of the trauma in 21 supination-eversion fractures and in 13 pronation-eversion fractures was most frequently faulty landing position or obstacles. The cause of seven supination fractures was oscillation of the parachutist whilst descending with sudden impact against the lateral aspect of the foot. For prophylaxis we recommend improvement of landing and steering techniques and the support of semi-calf boots.

Parachuting injuries: a study of 110,000 sports jumps.

A study was undertaken to examine the type, location, incidence and mechanism of injury sustained by amateur parachutists in Denmark during a five-year-period. A total of 110,000 parachute jumps resulted in six (0.005%) fatalities and 155 (0.14%) cases, requiring medical treatment. The latter group sustained 176 injuries of which 36.9% were significant soft tissue lesions and 63.1% fractures. Landing is the most dangerous part of the parachuting procedure, causing 83.8% of the accidents, while 9.3% were caused by faults during opening of the parachute. Based on the injury pattern, some modifications to the procedures and equipment are mentioned. A simplification of the parachute landing fall and the development of safer parachutes may reduce the incidence of casualties. An enforcement of the present regulations is necessary as many injuries are the result of noncompliance with regulations due to ignorance, inexperience or carelessness.