Lumbar spinal stenosis: assessment of long-term outcome 12 years after operative and conservative treatment.

The present study focuses on the long-term prognosis of radiographically verified stenosis of the lower lumbar spine. The purpose here was to describe the outcome 12 years after radiographic diagnosis of spinal stenosis and to identify factors predicting disability after operative or conservative treatment. Data were compiled on 75 patients (43 men and 32 women) with changes in functional myelography diagnostic for spinal stenosis. Their mean age at the interview 12 years later was 61 years. The sagittal diameter of the dural sac was measured from baseline myelographs at all intervertebral levels and was corrected for magnification. In the interview, subjective outcome assessment was obtained with a structured questionnaire, and the low-back disorder was scored using the Oswestry disability index. The sagittal diameter of the dural sac was severely stenotic (<7.0 mm) in 32 patients (26 operated), and moderately stenotic (7.0-10.5 mm) in 43 patients (31 operated). The severity of the stenosis significantly predicted disability, even when the effects of age, sex, therapy regimen, and body mass index were adjusted for. For moderate and severe stenosis, the adjusted mean Oswestry indices were 28.4 and 39.1, respectively (p = 0.01). Therapy as such (operative versus nonoperative) did not significantly correlate with later disability. The radiographic severity of lumbar spinal stenosis predicts disability independently of therapy regimen. Randomized clinical trials are needed to establish the indications for surgical and conservative treatment. Radiographic severity of the stenosis should be considered as an effect-modifying or confounding factor in clinical trials and other studies focusing on the outcome of lumbar spinal stenosis.

Costs and cost-effectiveness in hip and knee replacements. A prospective study.

The extensive benefits of the total hip (THA) and knee (TKA) replacements are well documented, but surprisingly little is known about their economics. We assessed costs, cost-effectiveness (C/E), and patient-related C/E variances in THA and TKA from data on 276 THA and 176 TKA patients. Patients with primary arthrosis, primary operation, and total joint replacement were recruited from seven hospitals between March 1991 and June 1992. Their use of health and other welfare services together with health-related quality of life (HRQoL) were measured before the surgery and at 6, 12, and 24 months postoperatively. HRQoL was assessed by the 15D, a 15-dimensional HRQoL instrument, and the Nottingham Health Profile. Costs were assessed from questionnaire responses, the Finnish Hospital Discharge Register, and Finnish Arthroplasty Register. Total hospital costs per patient were 45,000 FIM (US $10,500) for THA and 49,600 FIM (US $11,500) for TKA. Prosthesis costs comprised 21% of these costs in THA and 24% in TKA. On average, hip patients gained more in terms of HRQoL, and the operations were more cost-effective. The C/E ratio for younger (< or = 60 years) knee patients did not differ from those in all age groups of hip patients, whereas TKAs in those over 60 years had a worse C/E ratio compared with all other patient subgroups. It was concluded that allocation efficiency can be improved by considering not only the intervention but also patient characteristics such as age. Indeed, the C/E ratio varied more across age groups of knee patients than between average THA and TKA patients.

Quality of life and functional ability in hip and knee replacements: a prospective study.

The impact of hip (THA) and knee arthroplasty (TKA) on patients' health-related quality of life (HRQOL), physical ability and functioning was assessed in a two year follow-up study of 276 hip and 176 knee patients. The eligibility criteria were a diagnosis of primary arthrosis, a primary operation, and total joint arthroplasty. Patients were interviewed by questionnaire prior to the operation and 6, 12 and 24 months after the surgery. Subjective health outcomes were assessed with the Nottingham Health Profile and the 15D, a fifteen dimensional HRQOL measure. Patients' physical ability was assessed using measures of activities of daily living, and of physical mobility. Patient related outcome variations were analyzed by regression models. Major improvements were observed for pain, sleep and physical mobility. On average, in most of the quality of life dimensions the patients attained a similar quality of life as the comparable general population and only 4.7% of hip and 9.7% of knee patients had a worse HRQOL score at all three post-operative measurements than at baseline. Naturally, those with the poorest HRQOL pre-operatively gained most from the operation. High age did not lessen HRQOL gains from THA, but in TKA the oldest patients gained least in terms of 15D scores. Hip, but not knee patients with a long education tended to have greater improvements in quality of life and functional ability.

Health and quality of life before and after hip or knee arthroplasty.

The impact of hip and knee arthroplasty based on the patients' own evaluations of their health, quality of life, and physical ability was assessed using a cross-sectional study design. The eligibility criteria were a diagnosis of primary arthrosis, primary operation, and total joint arthroplasty. Preoperative hip and knee patient groups were compared with similar groups who underwent arthroplasty 2 or 5 years previously. Subjective health outcome was assessed with the Nottingham health profile and a 15-dimensional, health-related quality of life measure. Patients' physical ability was assessed using a measure of activities of daily living. Major improvements were observed for pain, sleep, range of motion, and physical ability. However, after surgery, patients were less healthy than the general population of the same age. The health status of patients operated on 2 or 5 years ago was similar, suggesting that health gains persist for several years.

Simo Antero Brofeldt--hospital leader, university teacher and military surgeon.

Simo Antero Brofeldt, Professor of surgery at the University of Helsinki from 1933 to 1942, was active in the planning and building of the Finnish Red Cross Hospital. He was the first chief surgeon of the hospital from 1932 to 1942, and consulting surgeon to the Finnish army High Command during the Second World War. He contributed to the development of trauma surgery, was acknowledged as a superb organizer and served the defence forces with honour.

Intensive physical and psychosocial training program for patients with chronic low back pain. A controlled clinical trial.

STUDY DESIGN: The authors conducted a controlled clinical trial with 1-year follow-up to define the effectiveness of an intensive physical and psychosocial training program on patients with low back pain. SUMMARY OF BACKGROUND DATA: The intervention group included 152 patients (mean age 40.5 yr, Million index 45.1/100), and the reference group included 141 patients (mean age 40.4 yr, Million-index 44.5/100). METHODS: The progressive intervention program consisted of intensive physical training and psychosocial activation. The outcomes were physical and psychosocial measures, the pain and disability index (Million), sick leaves, and occupational handicap. RESULTS: The intervention was more efficient with respect to physical measures and pain and disability index. There were only mild or no differences in changes between the study groups in psychologic variables, sick leaves, or retirement. CONCLUSIONS: The intervention program could improve physical disability, but to improve occupational handicap, activities of the whole society (social legislation, labor market policy) are needed.

Loosening of threaded acetabular components. Radiographic manifestations.

Radiographic signs of loosening were assessed, and their sequential appearance recorded, in a retrospective analysis of 20 loosened, threaded acetabular cups. There was radiographic evidence of loosening in 19 (95%) cups. In decreasing order of frequency, the radiographic manifestations included bone resorption between the threads in 19 (95%) cups, increased bone density above the cup in 15 (75%), continuous lucency around the cup in 14 (70%), axial migration in 9 (45%), and rotation in 6 (30%). The order of appearance of these radiographic manifestations was the same as the order of frequency of occurrence of the alterations. In the one patient with no radiographically detectable signs of loosening, the cup did not move freely but was easily detached during surgery. Early radiographic diagnosis of loosening requires accurate positioning of the patient in order for the radiographs to reveal bone resorption between the threads of the cup.

Wear of the polyethylene acetabular cup. Metallic and ceramic heads compared in a hip simulator.

Ultra-high molecular weight polyethylene acetabular cups of 5 different total hip systems (Müller, Mallory-Head, Lubinus, P.C.A. and Charnley-Elite) were worn on a new 5-station hip joint simulator. The cups articulated against modular metallic (stainless steel in Müller and Charnley-Elite, ion-implanted Ti-6Al-4V in Mallory-Head, and Co-Cr-Mo in Lubinus and P.C.A.) and modular alumina ceramic femoral heads for 3 million walking cycles. The mean wear rate of cups against alumina heads (range 0-5.7 mg/10(6) cycles, corresponding to 0-0.008 mm/year) was usually lower than against metallic heads (range 3.9-178 mg/10(6) cycles, corresponding to 0.005-0.24 mm/year). In the metal-head prostheses, the mean wear rate was highest against stainless steel heads, and lowest against ion-implanted Ti-6Al-4V heads. As the wear rates are compared with published clinical observations, it can be concluded that the hip joint simulator is capable of producing realistic wear rates; it is a useful instrument in the study of the wear behavior of new designs, materials, surface treatments and coatings prior to clinical trials. However, the taper-fit attachment of modular heads proved problematical, showing corrosion and wear at the conical head-spigot interface.

External transpedicular fixation test of the lumbar spine correlates with the outcome of subsequent lumbar fusion.

External transpedicular fixation was applied to the lower lumbar spine in a prospective study on 42 patients with chronic low back pain combined with suspected instability of the lumbar segments; the diagnosis was failed disk surgery, spondylolisthesis, and degenerative disk disease. The aim was to realign the involved segments, to restore disk height, and to record changes in pain and performance during the external fixation test. Pain was recorded on a visual analog scale, and performance was assessed using the Oswestry disability score. As independent observer assessed the test and treatment results. Twenty-nine patients experienced relief of pain and performed better in the fixator; they were subjected to anterior interbody fusion, the external frame being kept as a stabilizing device for an additional four months. Twenty-two patients have had follow-up evaluations for two years. One and two years after successful lumbar fusion, significantly (p < 0.02) better pain and performance scores were recorded; the results of lumbar fusion corresponded to the preoperative fixation test. A temporary external fixation test may be a useful procedure in patients considered for subsequent spondylodesis.

Bicycle accidents often cause disability--an analysis of medical and social consequences of nonfatal bicycle accidents.

Social and medical consequences of 278 children and 264 adults injured in bicycle accidents and seen in two hospitals in Helsinki in 1985-86 were analyzed. Information was collected from patient records, by means of a special questionnaire and by telephone interview. A child outpatient required 1.7 and a child inpatient 3.0 physician visits on an average, while adults required 2.2 and 4.9 visits, respectively. The average duration of hospital stay was 8 days for hospitalized adults and 6 days for children. Rehabilitative care outside the hospital was received by 6% of the adult outpatients and 25% of the inpatients, but none of the injured children. The mean duration of work disability was 82 days among inpatients, 11 days among outpatients, 127 days among the inpatients injured in motor vehicle collisions and 65 days among inpatients injured in other bicycle accidents. Of inpatients 32% and of outpatients 5% reported persistent (> 6 months) disability. Persistent disability was recorded in 11% of children, in 47% of adults and in 67% of elderly inpatients. Most serious consequences were due to intracranial injuries in motor vehicle-bicycle collisions. Of the hospitalized bicyclists 4% suffered from severe cognitive and behavioural changes or sense impairment and of adult inpatients 3% suffered from permanent work disability. The average costs of health and social services were about FIM 1000 per adult outpatient and FIM 13000 per adult inpatient. In prevention high priority should be given to motor vehicle collisions, head injuries and injuries among the elderly bicyclists.

Different healing patterns of experimental osteotomies treated by intramedullary nailing.

The healing of 52 diaphyseal osteotomies in rabbit tibiae was followed up histologically from 3 to 24 weeks after rigid intramedullary nailing. The histological evaluation was made from longitudinal sections through the osteotomy area. Particular attention was paid to the fracture healing pattern. A bulky periosteal response was visible in every specimen. At 24 weeks, the external callus was always well remodeled. The osteotomy line rapidly filled with bone from 6 weeks onwards. At 24 weeks, the site of osteotomy was detectable only on the basis of slight irregularity in the cortex. The secondary gap healing seen in 19 specimens was the most common type of bone union from 6 weeks onwards. In 13 specimens, the exact type of osteonal healing was not definable, since a solid union with good cortical reconstruction was always the final outcome. Altogether, four nonunions were detected throughout the study, none of these, however, in the specimens at 24 weeks. Considerable endosteal resorption was detected at 24 weeks, at which time at least one third of the original cortex had disappeared in all specimens. The rigid nail seems to ensure a relatively uneventful healing of the experimental osteotomies. Vast endosteal resorption and some nonunions make the use of medullary reaming in this connection doubtful.

Porous-coated anatomic (PCA) knee arthroplasty. 3-year results.

During 1984-1986, the authors used the PCA total knee replacement system on 92 knees in 86 patients who were followed for an average of 3.2 years (range, 2.2-4.5 years). Of the 92 knees, 42 were treated due to rheumatoid arthritis (RA) and 50 due to primary or secondary osteoarthrosis (OA). The average age of the patients was 60 years (range, 32-78 years). Seventy-one of the 92 prostheses were inserted without the use of methyl methacrylate cement. Fixation screws for the tibial plate were used in eight cases. One knee was revised due to ligamentous laxity by inserting a thicker tibia plate. Radiographically, there was radiolucency of more than 2 mm below two tibial plates (both RA), and four patellar components (2 RA, 2 OA; 4.3% of total) showed a radiolucent zone of 1 mm or more. Clinically, there were no evident loosenings. According to the Weinfeld scale, 80 knees (37 RA, 43 OA; P = NS) had an excellent result, 10 (6 OA, 4 RA) good, and 2 (1 OA, 1 RA) satisfactory. In comparison, the Hungerford scale gave 47 excellent, 30 good, 14 satisfactory, and 1 poor result. These results reflect that cementless PCA total knee replacement also appears to provide good fixation in both OA and RA knees.

Calcitonin treatment in lumbar spinal stenosis: a randomized, placebo-controlled, double-blind, cross-over study with one-year follow-up.

A randomized, placebo-controlled, double-blind, crossover study in 40 lumbar spinal stenosis patients with a 1-year follow-up showed that calcitonin had beneficial effects on the patients' symptoms without producing any notable side effects. Calcitonin had a clear analgesic effect. The mean of walking distance increased, but the crossover trend was not as good as the analgesic effect. Side effects such as erythema and nausea were usually mild and transient. Calcitonin therapy can be used as a conservative treatment in selected cases of lumbar spinal stenosis. When rest pain was mild or the walking distance was under 200-300 m because of neurogenic claudication, the effect of calcitonin seemed to be poor.

Registration of arthroplasties in Finland. A nationwide prospective project.

Data on hip and knee arthroplasties have been compiled on a nationwide basis in Finland since 1980. Forty-five major departments contribute to the study providing data on the type of operation, the implant used, the diagnosis, and the 1-year clinical results. In the case of revision, new data are sent to the register, enabling survivorship analysis. Between 1980 and 1988, 25,966 operations were reported. Fifty-six percent had been made for primary osteoarthrosis, 22 percent for rheumatoid arthritis, 6.3 percent for secondary arthrosis, and 0.5 percent for CDH. In 1988, the total number of arthroplasties was 4,628: about two thirds hip and one third knee replacements. The annual incidence of primary total hip arthroplasties in 1988 was 58 per 100,000 inhabitants and that for the knees 25 per 100,000 inhabitants. More than 40 percent of the patients were under 65 years of age. In the whole series, primary thromboembolic complications occurred in 1.4 percent, luxations in 1.4 percent, infection in 0.9 percent, and evacuated hematoma in 0.6 percent. The annual frequency of re-arthroplasty increased between 1980 and 1988 from 9.8 to 13.6 percent, indicating an increasing orthopedic work load in the future.

Orthopedic diseases and trauma in Finland. Trends in consumption of health services 1970-1985.

From 1970 to 1985, the total number of hospital admissions in Finland increased by 36 per cent, the number of admissions due to musculoskeletal disorders by 121 percent, and the admissions due to trauma by 38 percent. The combined share of musculoskeletal disorders and trauma in hospitals will grow to an estimated 18 percent of all the admissions by the year 2000. Of all the early pensions granted by the Social Insurance Institution, the share of musculoskeletal disorders as the main cause increased from 16 percent in 1970 to 25 percent in 1985.

Operations for the unstable cervical spine in rheumatoid arthritis. Sixteen cases of subaxial subluxation.

Sixteen patients with seropositive rheumatoid arthritis were operated on for subaxial subluxations. Four of the patients had slight, but progressive, tetraparesis, and 5 had severe or total tetraparesis; they were operated on 1-4 months after the first signs. Seven patients were treated for severe neck and shoulder pain. Nine patients had subluxation at the C3-4 level, the most common site, and 3 patients also had an atlantoaxial subluxation. Patients with cord compression were treated with posterior laminectomies and fusions that relieved the tetraparesis. Two patients died during the early postoperative period: 1 of a cardiac infarction and the other of pneumonia. During 4 (1.5-9) years' follow-up, 3 patients had new subluxations at other levels.