Observer variation in the radiographic classification of fractures of the neck of the femur using Garden's system.

By means of Kappa statistics, we calculated the inter- and intra-observer variation in the classification of fractures of the neck of the femur according to Garden's system. Radiographs of 96 consecutive patients were assessed independently by six observers who agreed on classification for only 14 fractures (15%). The level of agreement was poor for the overall classification (Kappa = 0.39). When reducing Garden's system into non-displaced (Stage I and II) and displaced fractures (Stage III and IV) the level of agreement became acceptable (Kappa = 0.68). However, problems remain in distinguishing Stage II and Stage III fractures, and further improvements in the classification system are necessary.

Functional closure of the femoral canal revealed by computed tomographic scanning.

The lacuna vasorum contains, as well as the external iliac vessels, a space called the femoral canal which allows pulsation and other changes in the diameter of the two vessels. The canal is closed by a connective tissue septum which is too weak to prevent a herniation alongside the vessels. The functional closure of the canal was investigated by artificial augmentation of the intraluminal pressure of the vein in five specimens and by computed tomographic (CT) scanning during a Valsalva manoeuvre in ten normal persons. In the abdomen the intraluminal and extraluminal pressures are raised in parallel, with no consequence for the diameter of the vessels. In the area of the lacuna vasorum the intravenous pressure is conveyed down to the first competent valve which is located 0.5 cm distal to the inguinal ligament, while the extraluminal pressure is reduced to normal. At each rise of the intra-abdominal pressure the vein will therefore bulge and exactly fill the empty space of the femoral canal thus preventing herniations by an on-demand mechanism. By CT scanning it was found that the vein in the femoral canal increased its diameter 2.5-3.0 times during the Valsalva manoeuvre.

Fractures after hemialloplastic hip replacement.

Forty-four patients sustaining ipsilateral femoral shaft fractures after hemialloplastic hip replacements are evaluated according to risk factors for the fractures, treatment and social costs. The fracture incidence was 0.10, and almost half of the fractures occurred within 1 year after the initial alloplastic operation. Possible factors increasing the risk of secondary fracture included loosening of the prosthesis (eight cases), osteoporosis (14 cases), varus angulation of the femoral stem (28 cases), calcar resorption (nine cases), major capsular calcifications (four cases), and cortical defects at the tip of the stem (three cases). The importance of correct insertion of the prostheses is emphasized. The degree of mobilization after fracture healing was overall reduced and most pronounced with increasing age and not correlated to treatment. The earliest mobilization was obtained in patients treated with long-stem prostheses supplemented with internal fixation, and this method of treatment is advocated.

Long-term follow-up of meniscectomy in athletes. A prospective longitudinal study.

We report the results of a prospective longitudinal study of 147 athletes who had had a meniscectomy for an isolated meniscus injury. The patients were reviewed in detail after median periods of 4.5 years and 14.5 years and the results analysed. The frequency of complaints related to the operation increased from 53% at 4.5 years to 67% at 14.5 years, while demonstrable knee instability increased from 10% to 36%. The incidence of radiographic changes of degeneration rose from 40% to 89% and at late review 8% of patients had definite osteoarthritis by the criteria of Ahlbäck (1968). In consequence 46% had given up or reduced their sporting activity, and 6.5% had changed their occupation. Radiographic deterioration started after the 4.5-year review in 49% of the patients and was more frequent after lateral than medial meniscectomy.

Ultrasonic demonstration of clinical and subclinical hepatic venous thrombosis in paroxysmal nocturnal haemoglobinuria.

Extensive hepatic venous thrombosis was demonstrated by ultrasonic scanning in three patients with paroxysmal nocturnal haemoglobinuria (PNH). The ultrasonography results were confirmed by X-ray venography. Two of these patients were without clinical symptoms of hepatic involvement apart from a slight increase in transaminases. This study indicates, firstly, that ultrasonic scanning is a rapid and reliable diagnostic tool in monitoring patients for this serious and often fatal complication, and, secondly, that hepatic venous thrombosis may be a more common complication in PNH than previously assumed.

Hemi-arthroplasty of the hip followed by ipsilateral fracture of the femoral shaft.

In a series of 74 ipsilateral fractures of the femoral shaft in relation to hemi-arthroplasties, treatment by a cemented long-stem total hip replacement was found to be superior to conservative treatment or internal fixation without removal of the prosthesis. Acceptable clinical results were obtained in 89 per cent of these cases.

A comparative analysis of x-ray findings of the lumbar spine in patients with and without lumbar pain.

Roentgenograms of the lumbar spine from 238 patients with lower back pain (LBP) with sciatica were compared with roentgenograms from 66 patients without LBP. No difference between the two groups could be demonstrated concerning the incidence of spondylosis and disc degeneration. Cases with wedge-shaped vertebral bodies are significantly more frequent in patients younger than 40 years old in the group having pain. The incidence of spondylosis and disc degeneration increase with increasing age.

Chondromalacia patellae: a radiographic study of the femoropatellar joint.

X-rays of 71 patients operated on for chondromalacia patellae were examined in order to obtain a comprehensive picture of the radiographic changes in this disease. Ninety-seven patients with a normal patellofemoral joint - found at operation - were used as a control group. We found a significantly higher frequency of patella alta and the presence of Haglund's excavation in patients with chondromalacia but had to conclude that ordinary X-rays cannot be used to confirm the diagnosis chondromalacia patellae.

Extraperitoneal perforation of the rectum during barium enema.

During barium enema, barium pentrated the rectum to the perirectal extraperitoneal tissue in six patients. Four of these died, and the two survivors have permanent colostomies. The incidence of this rare complication may be further reduced if barium enema is postponed after instrumentation of the rectum, the enema can not lifted more than one meter, the balloon not distended too much, the tip of the balloon catheter made very short, and the personnel in the radiological department made aware of the complication. The complication is probably best treated by prompt diverting colostomy, drainage of perirectal tissue, and antibiotics.