Treatment of non-union after tibial shaft fracture with a full cortical thickness inlay bone graft.

Twenty-seven non-infected delayed union or non-union fractures of the shaft of the tibia in 26 patients were operated on with a full cortical thickness inlay graft taken from the injured leg. The initial trauma was moderate in 9 fractures and severe in 18. Fifteen fractures were closed injuries and 12 open. The fracture pattern was longitudinal in 5 cases, transverse in 11 and communited in 11. Surgery was performed 12 to 72 weeks (mean: 30 weeks) after the fractures had been sustained. All fractures healed after the bone grafting procedure. The time until union was established after surgery ranged from 6 to 37 weeks (mean: 17 weeks). The healing time was neither influenced by the initial type of fracture pattern (p > 0.05) nor by the fracture age at surgery (r = -0.21). Of 13 patients re-examined 8 to 16 years after surgery, the clinical results were classified as excellent in 8, as fair in 2, and as poor in 3 patients.

Neck and shoulder complaints among sewing-machine operators: a study concerning frequency, symptomatology and dysfunction.

The occupation of sewing-machine operators (SMO) involves monotonous and repetitive tasks, performed in a work position equivalent to a static component of muscular load on the neck and shoulder. The present study concerns the occurrence of neck-shoulder problems in a population of SMO. A total of 224 SMO from four textile factories in the western part of Sweden were subjected to a comprehensive questionnaire about demographic, vocational, medical and psychosocial data. The Nordic Ministry Questionnaire specifically directed towards neck-shoulder complaints showed a prevalence rate during the last 12 months of 75% and during the last seven days a rate of 51%. Daily problems were experienced by 26%. Some 27% had had problems leading to restraints in work time and 37% in leisure time. Those SMO screening positive were clinically examined in an attempt to describe the clinical picture behind the complaints. Diagnoses were made according to specific criteria. The tension neck syndrome (TNS) was most frequent, followed by the cervical syndrome. In half of those examined, symptoms and findings were too unspecific for diagnosis. A positive correlation between the TNS and working hours per week suggests a daily prolonged static load on the neck and shoulder to be of importance for neck-shoulder problems among the SMO.

Surgery for soft tissue sarcoma in the extremities. A multivariate analysis of the 6-26-year prognosis in 137 patients.

In 137 patients with soft tissue sarcomas in the extremities, the influence of patient and tumor characteristics and surgical procedures on prognosis was studied using a multivariate statistical analysis. The minimum follow-up time was 6 years, and no patient was lost to follow-up. Eighty-nine patients were referred with the tumor intact (primary series), while 48 were referred after biopsy or with local recurrence after previous surgery (secondary series). The frequency of amputation was 15 percent in the primary series and 48 percent in the secondary series. A local, function-preserving operation with a wide margin was performed in 37 patients without biopsy (clinical diagnosis alone). Local control of the disease was obtained in all but one of these patients without any adjunctive treatment. Independent, unfavorable factors concerning local recurrence were advancing age, open biopsy, and marginal surgery. Independent, unfavorable factors concerning survival were advancing age, increasing histologic malignancy grade, and ablative surgery. A tumor-related death was observed in 0, 29, 47, and 67 percent of the patients with tumors of malignancy grades I, II, III, and IV, respectively.

Rotational osteotomy of the humerus for posterior instability of the shoulder.

We evaluated twelve shoulders (ten patients) that had recurrent, painful posterior instability and were treated by external rotational osteotomy of the humerus. The length of follow-up ranged from two to twelve years. The patients rated the result as excellent or good in ten of the twelve shoulders. Objectively, two shoulders were rated as excellent; eight, as good; and two, as fair. There was recurrent instability in one shoulder that had had multidirectional instability. One pseudarthrosis, which persisted for ten years, was revealed on the follow-up radiographs.

Extra-abdominal desmoid tumors.

A follow-up study of 53 patients with extra-abdominal desmoid tumor is presented. Fine-needle aspiration biopsy seemed to be valuable in the differentiation between a desmoid tumor and a truly malignant soft tissue tumor. The angiographic pictures did not differ from those of other soft tissue tumors, but valuable topographic information was obtained from the angiography in the preoperative planning. The overall local recurrence rate was 17/44, and 15 of the recurrences occurred within the first 2 years. Complete removal of the affected muscle or muscle group is recommended. Local control can be achieved by non-ablative surgery even after multiple recurrences. Only one out of 53 patients died of the tumor disease. Radiotherapy can be attempted in extensive tumors, and amputation should be reserved for tumors which have failed to respond to this treatment.

Computed tomography of lipomatous and myxoid tumors.

Thirty-two lipomatous and myxoid tumors were examined by computed tomography (CT). An attempt was made to correlate the radiographic appearance of the tumor to different histologic types of these tumors. It was found that a well delineated lipomatous lesion with uniform radiographic density, an attenuation value below -73 Hounsfield units (HU) and absence of contrast enhancement can be considered strongly suggestive of a benign lipoma. Atypical lipomas, myxoma and well differentiated liposarcomas have good delineation against the surrounding tissue with no peripheral hypervascularity in the majority of cases. The attenuation values varied between -83 and +38 HU. Liposarcomas of myxoid type, mixed myxoid and round-cell type, round-cell type, and pleomorphic type were all poorly delineated with attenuation values between +12 and +38 HU and with varying contrast enhancement. Thus CT can be considered to play an important role in the preoperative evaluation of lipomatous and myxoid tumors of the soft tissues. Besides valuable topographic information CT helps, to some extent, to differentiate between various types of lipomatous tumors.

Scapulectomy for malignant tumor. Function and shoulder strength in five patients.

Function and muscular strength were studied in five patients who had undergone either total or subtotal scapulectomy for malignant tumor. We found a striking difference in the functional impairment between the two patients with total and the three patients with subtotal scapulectomy. The latter three patients were able to handle light objects with their hands over their heads, and reached or nearly reached the horizontal plane in flexion and abduction of the shoulder. The two patients with total scapulectomy had a flexion and abduction range between 40 and 50 degrees. The mean isometric muscle strength in flexion relative to the non-operated side was 17 and 37 per cent for patients with total and subtotal scapulectomy, respectively, and the abduction strength 14 and 44 per cent, respectively. After scapulectomy, a reasonably good function can be expected, especially if it is possible to preserve the glenoid fossa and/or the acromion.

Shoulder function after deltoid muscle removal.

Postoperative function and muscular strength of the shoulder joint were studied in five patients who had undergone extirpation of the deltoid muscle because of a soft tissue tumor. No patient had significant functional impairment but all had a slightly limited range of active abduction and flexion. The strength reduction did not exceed 40 per cent in any position.

A modified Hauser procedure for recurrent dislocation of the patella. A long-term follow-up study with special reference to osteoarthritis.

A modified Hauser operation was used for the treatment of recurrent dislocation of the patella. Thirty-seven patients (40 knees) were traced for the purpose of long-term follow-up with regard to subjective and objective results and the degree of osteoarthritis in the patellofemoral joint. The mean follow-up time was 18 years. Only 12% of the patients had objectively satisfactory results, but 48% were satisfied with their operation. There was no correlation between the opinion of the patients and the objective findings. Dislocation recurred in 20% of the knees. More than two-thirds of the patients had some degree of osteoarthritis, and a poor result was always combined with osteoarthritis. The incidence of osteoarthritis increased with the time of follow-up and the age of the patient, but it was also found in younger patients. It seems that distal realignment of the patella enhances the development of osteoarthritis.

Amputation for tumor of the upper arm.

In a 10-year period 35 patients underwent a proximal amputation of the upper limb because of a malignant tumor. In 27 patients a forequarter amputation was made, in one a humeroscapular disarticulation and in seven an amputation through the humerus. The observed 5-year survival was 23 per cent. Twelve out of 23 patients followed for at least 3 years also survived 3 years. Fifteen living patients were questioned concerning prosthetic use and social and psychologic factors. Only three patients used a functional (mechanical) prosthesis and only five used a cosmetic prosthesis. The other seven patients rejected the use of a prosthesis. Half of the patients had the same occupation postoperatively as preoperatively. Activities of daily living did not constitute any major problem. One of three housekeepers needed daily help. One patient seemed to have suffered obvious psychologic damage.

A multivariate analysis of the prognosis after surgical treatment of malignant soft-tissue tumors.

Ninety-seven patients who had received their primary and definitive surgical treatment for a soft-tissue sarcoma during the years 1956--1976 were studied with respect to local recurrence, metastasis, and survival. The aim of the treatment was to eradicate the tumor while preserving good function. The influence of host and tumor properties and different diagnostic and surgical procedures on the prognosis was studied by means of nonparametric multivariate analysis. Ninety-four percent of the tumors were located in the extremities. Malignant fibrous histiocytoma was the most common histologic type. A four-grade scale of histologic malignancy was used. Eighty-eight percent of the tumors were Grade III or IV. In 85% of the patients with an extremity lesion, local extirpation was carried out. The overall local recurrence rate was 21.7% and in 76 patients who underwent an adequate surgical procedure it was 6.6%. The overall five-year survival rate was 59%. The survival depended on the local control of the primary tumor, which was related to the adequacy of the surgical procedure and to the histologic grade of malignancy. No patient with a Grade I or II tumor died. The five-year survival rate for patients with Grade III tumors was 68% and for patients with Grade IV tumors 47%.

A technique for measurements of plantar flexion torque with the Cybex II dynamometer.

A standard procedure for measurements of calf muscle strength with an isokinetic dynamometer is presented. The method is based on recordings in supine position, with a straight knee joint and a firm fixation of the foot in a new device. The reproducibility was studied by a test-retest procedure in ten testing subjects. The methodological error varied between 5 and 10% and the coefficient of reliability varied between 0.94 and 0.98. The coefficient of variation when measuring one testing subject at ten different occasions was smaller at isokinetic than at isometric measurements.

Function after removal of various hip and thigh muscles for extirpation of tumors.

Forty-six patients who had undergone excision of one or more well defined hip and/or thigh muscles because of a soft-tissue tumor or a tumoriform lesion were investigated with respect to the function of the operated limb and the isometric and isokinetic strength of the affected motion or motions, relative to the non-operated side (percentage). Hip flexion: Loss of the iliopsoas caused slight impairment of function. The flexion strength decreased with increasing flexion of the hip joint. Loss of the rectus femoris reduced the isometric strength by 37 and the isokinetic strength by 17 per cent. Hip abduction: The strength reduction was only about 50 per cent and the impairment of function only slight or moderate even in patients with extensive loss of abductor muscles. Hip adduction: Removal of all three prime adductors (longus, brevis, magnus) caused a strength reduction of about 70 per cent but the impairment of function was only slight or moderate. Hip extension: Loss of the gluteus maximus caused only a small strength reduction and no impairment or only slight impairment of function. Significant strength reduction was only seen when all hamstrings had been removed. Knee extension: Loss of one, two, and three of the quadriceps muscles reduced the isometric strength by 22, 33, and 55 per cent, respectively. The isokinetic strength was reduced somewhat more. The strength reduction usually had to exceed 50 per cent to cause more than slight impairment of function. Knee flexion: Loss of the semitendinosus, the biceps femoris, and all the hamstrings reduced the isometric strength by 24, 28, and 67 per cent, respectively. The isokinetic strength was reduced somewhat less. Loss of one of the hamstrings usually caused no impairment of function whereas loss of all three resulted in moderate impairment of function.

Function after anterolateral resection of the lower leg for extirpation of tumors. Extension and pronation of the foot restored by transfer of the tibialis posterior muscle.

A function preserving method for radical removal of tumors located anterolaterally in the lower leg is described. The loss caused by the inclusion of all extensors and pronators of the foot in the surgical specimen is compensated for, to a large extent, by transfer of the tendon of the tibialis posterior muscle to the conjoint tendons of the extensor digitorum longus and peroneus tertius. The function after such an operation has been studied in two patients using various methods including strength measurements and, in one of them, electromyography.

Microvascular osteocutaneous groin flap in the treatment of an ununited tibial fracture with chronic osteitis. A case report.

A 37-year-old man with an ununited tibial fracture combined with a significant skin defect underwent a microvascular transfer of an island osteocutaneous flap of groin skin and iliac crest bone. The bone component of the flap was shown to be a living transplant by the observation of brisk cancellous bone bleeding when the flap was isolated on its vascular stalk; by rapid fracture healing (weight-bearing 15 weeks postoperatively); and sequential bone scan investigations. Various aspects of the flap blood supply, particularly to bone, are discussed, and reference is made to the use of a more suitable vessel system.

Measurement of strength of hip joint muscles.

A standard procedure for measurement of hip muscle strength with an isokinetic dynamometer is presented. The method is based on recordings in supine position and firm stabilisation of the pelvis. Abduction and adduction movements can be done without friction. The position of the dynamometer and its rotation centre is indicated. The reproducibility was studied by a test-retest procedure. The methodological error varied between 4% and 10.5% and the coefficient of reliability varied between 0.80-0.99. The coefficient of variation when measuring one testing subject at ten different occasions was smaller at isokinetic than isometric measurements.

Strength of plantar flexion and function after resection of various parts of the triceps surae muscle.

Nine patients who had undergone resection of various well defined parts of the triceps surae muscle because of tumour were examined. The function was estimated from the patient's history and the muscle strength was measured statically and dynamically using a Cybex II dynamometer. Two patients reported slight symptoms. The loss of strength was less than one might expect from theoretical calculations. The strength of the operated limb showed a particular pattern depending on the part resected. From this pattern it was concluded that the soleus is more active when the foot is dorsiflexed and the gastrocnemius more active when the foot is in plantar flexion, and that the gastrocnemius is most important in quick movements of the foot.

Extirpation of tumors located near the thoracic cage. A method for increasing the margin of healthy tissue on the deep side of the tumor.

When an aggressive tumor develops in a flat muscle near the thoracic cage the question may arise as to how achieve an adequate margin on the deep side of the tumor. This is especially the case if the tumor has recurred after a previous non-radical operation. A method is described by which the external thoracic fascia, the external intercostal musculature, and the periosteum on the external surface of the ribs can be included in the specimen as a continuous wall of healthy tissue on the deep side of the tumor. This technique has been used in 11 patients, 9 of whom had undergone one or more inadequate operations earlier. Eight patients had a malignant tumor, three an extra-abdominal desmoid. In one of the latter patients, in whom a recurrent tumor was adherent to rib periosteum, the method was unsuitable. In the other patients the method appears to have been adequate for local control of the tumor.

Factors influencing results of high tibial osteotomy in gonarthrosis.

Based on our results with high tibia osteotomy for gonarthrosis in 96 knees, the type of primary deformity was found to significantly influence the patient's subjective assessment of the results. Knees with valgus deformity secondary to changes in other joints are not suitable for correction by HTO. Knees with varus deformity exceeding 10 degrees and with roentgenological signs of reduction of the medial tibial condyle are seldom corrected by HTO and the results in these knees are poor. There is a clear correlation between patient's satisfaction with HTO done for gonarthrosis and the correction of femorotibial deformity.