[To whom are roller-skaters harmful? A questionnaire among roller-skaters]. / Hvem er rulleskøjter farlige for? En spørgeskemaundersøgelse blandt rulleskøjtebrugere.

The number of roller-skaters in Denmark has increased visibly during recent years. We found a high incidence of serious injuries among patients (n = 112) who attended our emergency department from June 14th to October 14th 1996. One third of the patients were diagnosed with a fracture. Increasing numbers of the injured roller-skaters use protective gear, mostly wrist splints (37%). Wrist splints probably reduce the number of fractures, but do not completely eliminate the risk of fracture. It seems that roller-skaters are less harmful to other pedestrians than previously assumed.

[Infectious arthritis in a patient with rheumatoid arthritis]. / Infektiøs arthritis hos en patient med reumatoid arthritis.

Patients with rheumatoid arthritis are at greater risk of developing joint infections than any other group of patients. Diagnosis is often delayed because of the difficulties in distinguishing between a flare-up and a septic affection of the joint. A case of septic arthritis with multiple joint involvement and lethal outcome despite extensive antibiotic treatment and successive surgical procedures is presented. The patient developed osteomyelitis and multiple organ failure. In order to reduce morbidity and mortality from septic arthritis, early joint puncture and subsequent antibiotic treatment is essential.

Efficacy and safety of prolonged thromboprophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty--the Danish Prolonged Prophylaxis (DaPP) Study.

The aim of this study was to compare the efficacy and safety of prolonged (35 days) thromboprophylaxis with a standard length (7 days) regimen of a low molecular weight heparin in patients undergoing total hip arthroplasty. The study was multicentre, randomised, double-blind, and prospective with two groups. Following seven days on a standard length regimen of dalteparin (5000 antifactor Xa units subcutaneously once daily starting 12 h before surgery), patients were randomized to continue the prophylaxis with either subcutaneous injections of dalteparin or placebo injections for a further 28 days. Efficacy was evaluated at the end of the study (day 35) in all patients with bilateral ascending phlebography to detect deep vein thrombosis. Bleeding complications and other adverse events were registered throughout the study period. Three hundred consecutive patients agreed to participate before the operation: 281 were finally randomised and 215 completed the study; two patients died before randomisation; 17 developed deep vein thrombosis; none developed pulmonary embolism; and five of 113 patients (4.4%, 95% CI 1-10%) developed deep vein thrombosis in the dalteparin group, compared with 12 of 102 (11.8%; 95% CI 6-20%) in the placebo group (p=0.039). Deep vein thrombosis in the proximal veins was diagnosed in one patient (0.9%; 95% CI 0-5%) in the dalteparin group, and in five (5.0%; 95% CI 2-11%) in the placebo group (p=0.076). Major bleeding was observed in one patient in the placebo group; minor bleeding complications and adverse events were equally distributed between the groups. We concluded that prolonged (35 days) thrombo prophylaxis with dalteparin is more effective than a standard length (7 days) regimen without increased risk of bleeding complications or other adverse events.

[Reconstructive joint surgery and rheumatoid arthritis. Status over a developing field]. / Rekonstruktiv ledkirurgi og reumatoid arthritis. Status over et udviklingsområde.

Rheumatoid arthritis has a prevalence of between 1% and 2%. The majority of patients face the prospect of surgical treatment of joints, that do not respond to medical treatment. With respect to the extensive development in joint surgery during the last decade, today's recommendations for surgical treatment of the individual joints are surveyed.

Prevention of thromboembolism with use of recombinant hirudin. Results of a double-blind, multicenter trial comparing the efficacy of desirudin (Revasc) with that of unfractionated heparin in patients having a total hip replacement.

Specific inhibition of thrombin is a new method for the prevention of postoperative deep-vein thrombosis. The objective of this multicenter, randomized, double-blind study was to compare the efficacy and safety of desirudin (Revasc, CGP 39393; fifteen milligrams two times a day) with that of unfractionated heparin (5000 international units three times a day) in patients having a primary elective total hip replacement. The medications were administered subcutaneously, starting preoperatively and continuing for eight to eleven days. The primary end point was a confirmed thromboembolic event during the treatment period. The presence of deep-vein thrombosis was evaluated with bilateral venograms, which were centrally assessed by two independent radiologists. A total of 445 eligible patients were randomized: 220, to management with heparin, and 225, to management with desirudin. A per-protocol analysis of efficacy was performed for the 351 patients (79 per cent) for whom an adequate bilateral venogram had been made within eight to eleven days after the operation or who had had a proved thromboembolic event. The prevalence of confirmed deep-vein thrombosis was thirteen (7 per cent) of 174 patients who had received desirudin and forty-one (23 per cent) of 177 patients who had received heparin, a significant difference (p < 0.0001). The prevalence of proximal deep-vein thrombosis was also significantly reduced (p < 0.0001), by 79 per cent, in the group that had received desirudin (six [3 per cent] of 174 patients) compared with in the group that had received heparin (twenty-nine [16 per cent] of 177). There were no confirmed pulmonary embolisms or deaths during the period of prophylaxis. During a six-week follow-up period, pulmonary embolism was confirmed in four patients, all of whom had received heparin. There was no significant difference between the treatment groups with respect to bleeding variables or bleeding complications. These data demonstrate that a fixed dose of fifteen milligrams of desirudin, started preoperatively and administered subcutaneously twice daily for at least eight days, provided effective, safe prevention of thromboembolic complications, with no specific requirements for laboratory monitoring, in patients who had a total hip replacement.

Triplex US in the diagnosis of asymptomatic deep venous thrombosis.

PURPOSE: To evaluate the accuracy of triplex ultrasound (TUS) compared with venography as a screening test for deep venous thrombosis (DVT), and to evaluate interobserver variation in the interpretation of the venographic studies. MATERIAL AND METHODS: A total of 133 postoperative hip fracture patients, asymptomatic of DVT, were prospectively examined with TUS and venography. All venograms were reviewed blindly and in case of disagreement a consensus was arrived at. RESULTS: The incidence of DVT was 20%, with isolated calf vein thrombi in 63% of the cases. There were 7 false-negative and one false-positive result/s at TUS, with a sensitivity of 74%, specificity of 99% and accuracy of 97%. The kappa values ranged from 0.58 to 0.82. The false-negative results were all caused by missed calf vein thrombi in technically inadequate examinations. At sonography 2% of vein segments were noninterpretable, compared to 29% at venography. CONCLUSION: Venous US is less sensitive as a test for DVT in this study of asymptomatic patients than in earlier studies on symptomatic patients. Still, sonographic screening of high-risk patients would be both effective and cost effective. Fresh thrombi may cause a false-negative compression test.

Location of postoperative deep vein thrombosis in relation to age and survival.

The aim of the study was to determine the effect on long-term survival of the location of DVT in relation to age groups and side of operation. 1310 patients undergoing total hip arthroplasty and who participated in one of 7 randomized, prospective clinical trials with thromboprophylaxis were included in this analysis. A trend analysis showed that the incidence of proximal and distal DVT increased significantly with age (p<0.05). In patients older than 64 years of age the relative risk of death was non-significantly higher when proximal DVT was present compared to patients without DVT and the relative risk of death was non-significantly higher in patients older than 74 years of age when distal thrombi was present compared to patients without DVT. The test for trend showed an increase with age in the incidence of both ipsi- and contralateral DVT; the increase was significant in patients with contralateral DVT (p<0.05). The relative risk of death was higher (of borderline significance) in patients older than 74 years of age with contralateral DVT.In conclusion, the pattern of location of asymptomatic deep vein thrombosis changes with increasing age. The location of asymptomatic and treated DVT has no significant influence on long-term survival.

[Supinator syndrome. Entrapment of the posterior interosseous nerve]. / Supinatorlogesyndrom. Entrapment af ramus profundus n. radialis.

Activity related pain on the lateral side of the elbow or proximal on the forearm may be caused by compression of the posterior interosseous nerve in the radial tunnel. A number of different specialties can be involved in this patient. Often there is no effect of conservative treatment. Several investigations show that the condition can be treated surgically with good to excellent results in the majority of patients. Often the patients suffer a number of concomitant overuse syndromes. The clinical characteristics and the surgical approach to the problem is described and illustrated by two case stories.

[Brodie abscess. Primarily misinterpreted as traumatic lesion]. / Brodies absces. Primoert fejltolket som traumefølger.

Two case histories are presented. In the first, a 49 year-old man fell on his right hip. He was able to walk, but because of pain he came to our emergency room. Radiographics gave an impression of an undislocated intertrochanteric fracture, scintigraphy confirmed the suspicion. There were no signs of infection. On starting osteosynthesis with the drilling of a hole in the lateral cortex, discharge of pus was observed and curettage of the abscess cavity was performed. In the second, a 21 year-old man hit his right knee against a table. Because of pain he was admitted to hospital. Primary signs of a lesion of the lateral meniscus were found and arthroscopy was scheduled. When readmitted we found signs of an infection and X-ray revealed a Brodie's abscess in the proximal tibia. The abscess cavity was opened and curettage was performed. Radiographics, scintigraphics, blood parameters and pathological and microbiological investigations revealed primary chronic osteomyelitis in both patients. Antibiotic therapy was instituted and six weeks after primary operation bone transplantation was performed. The further course was uncomplicated.

Survival in patients undergoing total hip arthroplasty in relation to thromboprophylaxis with low molecular weight heparin: a long-term follow-up study.

The aim of the study was to determine the long-term survival in patients undergoing total hip arthroplasty in relation to type of perioperatively administered thromboprophylaxis. Patients from seven randomized controlled trials of the effect of thromboprophylaxis on development of early thromboembolic complications after total hip arthroplasty were included in a follow-up analysis with death as the end-point. There was no difference in survival between groups receiving active thromboprophylaxis, but there was a general trend towards a better survival in the 3 placebo groups compared with low molecular weight heparin (LMWH), (RR: 1.53; C.I.: 1.04-2.25). There was a significant excess of cardiovascular deaths in the LMWH groups (RR: 2.48; CI: 1.45-4.24). Long-term prospective studies should be performed to assess the long-term effect of various thromboprophylactic regimens on morbidity and mortality after total hip arthoplasty.

Experimental implant-related osteomyelitis induced withStaphylococcus aureus.

Experimental knee-implant infection was induced in the rabbit knee with a strain (1369,phage type 85,a laboratory strain) of Staphyloccus aureus. The experimental model was adapted from an experimental study in rabbits by Gudmund Blomgren, 1981. In these experiment's osteomyelitis was induced with an noculum of 100,000 bacteria in the tibia and femur. In one series we used gentamicin impregnated bone cement and in the other series dicloxacillin was given intravenously. The controlgroup, four rabbits had no supplemental antibiotics. The animals were monitored by clinical observation, microbiological, histological and antibody methods. Only in the controlgroup without supplemental antibiotics we would see manifest inflammation around the prosthesis with increased antibody titre. With supplemental antibiotics no bacteria was found around the prosthesis.The gentamicin concentration was measured in bone from femur, tibia and from the jointfluid. A high level of gentamicin was found in the bone but not in the joint fluid. The animal model was excellent to create a model for human total joint replacement to study the dissemination of localy and intravenously injected bacteria to the artificial joint. The use of either systemic or locally administered antibiotics as prophylaxis avoided development of infection.

Resection arthroplasty of the forefoot in rheumatoid arthritis cases.

Resection arthroplasty of the forefoot was performed in 30 patients (48 feet) with rheumatoid arthritis. A Keller/Clayton procedure yielded good results, whereas a less radical operation (Hybbinette) created poor results. Reoperation following failed Hybbinette operations was possible.

[Synovectomy in rheumatoid arthritis]. / Synovektomi ved reumatoid arthritis.

Surgical synovectomy in the treatment of rheumatoid arthritis has been performed for more than a 100 years, and yet the definite indication has not been made clear. Synovectomy has a convincing, but mostly time-limited effect on pain and articular hydrops, but the radiological progression continues almost undisturbed. Histological evaluation of the regenerating synovial membrane has now shown a tendency towards reversing to baseline within about a year. The difficulties in evaluating the operation are caused by the lack of comparable randomized studies performed on large populations, treated in a double-blind fashion and examined in cooperation between surgeon and rheumatologist.

Pseudarthrosis of the acromion--a differential diagnosis in anterolateral shoulder pain.

A case of longstanding posttraumatic anterolateral shoulder pain in a 25-year-old woman is presented. It was primarily unsuccessfully handled as impingement syndrome but turned out to be caused by pseudarthrosis of the acromion. The abnormality was not apparent on plain X-ray film. The suspicion was raised after scintigraphy, which showed increased density in the acromion. The diagnosis was made by computerized tomography and confirmed and treated successfully surgically.

[Antibiotic prophylaxis in Danish orthopedic alloplastic surgery]. / Antibiotikaprofylakse i dansk ortopaedisk alloplastikkirurgi.

In order to assess the routine use of prophylactic antibiotics (AB) in arthroplastic surgery in Denmark, questionnaires were sent to all Danish orthopaedic departments and all general surgical departments that perform orthopaedic surgery. Fifty-six departments (93%) returned the questionnaires. All departments use prophylactic AB in primary knee and hip arthroplasty and in revision arthroplasty. In addition, all departments but one use prophylactic AB in arthroplasty secondary to osteosynthesis. The largest group of departments uses penicillinase-resistant penicillin (PRP) in their standard prophylaxis regimens. The second largest group uses second generation cephalosporins. With one exception, all use cefuroxime. A small group uses other types of AB. Fifteen percent of the departments combine systemic AB with gentamicin bone cement (GC) in primary hip arthroplasty, whereas 22% use this combination in primary knee arthroplasty. Significantly more departments use GC in revision arthroplasty (89%) and in arthroplasty secondary to osteosynthesis (63%). Prolonged antibiotic prophylaxis (beyond 24 hours) is practised to a significantly higher degree in revision arthroplastic surgery than in the primary arthroplasties. In conclusion, one of two homogeneous groups of prophylactic AB is used in arthroplastic surgery in Denmark as prescribed in the literature.

Arthrodesis after infected knee arthroplasty using long arthrodesis nail. A report of five cases.

Safe methods to perform secondary arthrodesis in the treatment of infected total knee arthroplasty (TKA) after revision arthroplasty has failed are increasingly needed as TKA becomes more common. Possible treatments include external fixation (with single- or double-framed fixators), internal fixation, or amputation. This article reports five cases of infected TKA treated with arthrodesis using a long intramedullary nail. Arthrodesis was performed in a two-stage manner, with surgical revision and insertion of a long intramedullary nail. All arthrodeses healed on an average of 4.8 months.

[Hemi-alloplasty in the treatment of proximal humeral fractures]. / Hemialloplastik ved behandling af proksimale humerusfrakturer.

Twenty-four cases of displaced proximal humeral fractures were treated by hemiarthroplasty. No postoperative infections were seen. Follow-up was 24 month (range 12 to 62) in 19 patients. Pain relief was satisfactory in all patients but one. Functional results according to a modified Neer score system were good in nine, fair in eight and poor in two cases. No statistical differences in results in relation to postinjury delay or other parameters were found. Hemiarthroplasty is thus a safe treatment for displaced humeral fractures with a satisfactory end result.

Computer registration of infections used to measure the effect of prophylactic antibiotics on postoperative infections following osteosynthesis in hip fractures.

Continuous registration of operations and wound infections was used to demonstrate the effect of prophylactic antibiotics in hip fracture osteosynthesis. In order to monitor wound infections and other postoperative complications in an orthopaedic department, 2 years' data on 688 patients with hip fractures, were entered into a personal computer program. During 1990, there was no formal policy for antibiotic prophylaxis; during 1991 prophylactic cefuroxime was recommended for osteosynthesis of hip fractures. In 1990 56% of patients were given prophylaxis and in 1991 this rose to 79%. Overall, 68% of patients had prophylaxis. The overall rate of deep wound infections (DWI) was significantly lower in patients treated with prophylactic antibiotics (0.6%), compared with those without prophylaxis (4.6%). Patients with DWI were admitted to the hospital for an average of 43.7 days, compared with 14.6 days for patients without complications. We recommend the use of prophylactic cefuroxime in hip fracture osteosynthesis. Computer registration of complications is a useful method for clinical quality control in an orthopaedic department.

Removal of internal fixation--the effect on patients' complaints: a study of 66 cases of removal of internal fixation after malleolar fractures.

To estimate the effect of removal of internal fixation after treatment of malleolar fractures on postoperatively presented complaints, we retrospectively evaluated 66 patients by their records and by personal questionnaires. Of all the patients, 89.4% had one or more complaints. These were typically soreness over implant and cicatrix, reduced movement of the ankle joint, and strain-related pain. About 75% of these patients reported improvement after removal. The AO mode of fixation, i.e., typically by lateral semitubular plating and transsyndesmotic screw and a medial screw or pins, and the Wiberg-Cedell mode, i.e., typically consisting of lateral single or double cerclage and staple and medial pinning, constituted the principal groupings of the patients. The two groups were comparable. In this series, we found significantly more complaints associated with the AO mode in the postoperative period. We conclude that removal of internal fixation after malleolar fractures is indicated when common types of complaints are presented.