Piroxicam and indomethacin suppositories for painful coxarthrosis.

Six orthopaedic clinics in Sweden made a comparison of the effects and side effects of Piroxicam (20 mg) and Indomethacin (100 mg) suppositories in 261 patients with painful coxarthrosis on the waiting list for total hip replacement (THR). The study was designed as a single blind study over 4 weeks. Amount of pain and range of motion was registered before the trial and compared with findings after 4 weeks, including reported side effects. Both drugs gave satisfactory pain relief without any appreciable variation on weightbearing or at rest. On the other hand, the trial showed a significant difference (p = 0.0033, Student's-test) between the two drugs as regards the frequency of side effects from the lower gastrointestinal tract, where piroxicam had a lower rate compared with indomethacin. No serious complications occurred; 16 patients dropped out, 8 in each group.

Function after tibial osteotomy for medial gonarthrosis below aged 50 years.

Twenty-seven patients (28 knees), with a median age of 42 (27-50) years treated with a high tibial osteotomy for early medial gonarthrosis (Ahlbäck's Stage I) were examined after 11 (7-18) years. Twenty-four were men; 18 knees had had previous meniscus and ligament lesions. At follow-up, 22 knees were satisfactory and 9 patients managed high-activity sports or heavy work. In 25/28 knees, the arthrotic process had not progressed radiographically.

A guide instrument for high tibial osteotomy.

Fifty-two patients (52 knees) with medial gonarthrosis were subjected to high tibial osteotomy using the Tjörnstrand guide instrument. The intended wedge was calculated from a whole lower limb radiograph. The correction aimed at was an overcorrection of 4 degrees in valgus of the hip-knee-ankle angle. All but 1 case were corrected to +/- 3 degrees of the intended angle. All but two cases healed within +/- 3 degrees of the achieved surgical correction, i.e., a substantial improvement compared with our previous freehand technique where one fifth were outside this interval. We conclude that in knee surgery a guide is as important for osteotomies as for arthroplasties.

Coxarthrosis and labour.

To investigate whether environmentally associated stress may contribute to the development of coxarthrosis, 85 males with primary coxarthrosis and 262 male urological patients were questioned about their occupation, and their hips were graded radiologically. Patients with coxarthrosis had been more frequently exposed to heavy labour, heavy lifting, and much tractor driving. Our results indicate that environmentally associated stress, as reflected by a varied life style or occupation, may contribute to the development of coxarthrosis.

Survival of knee arthroplasties for rheumatoid arthritis.

During a 15-year period, 498 primary knee arthroplasties for chronic rheumatoid and related arthritides were performed. Ninety arthroplasties where prosthetic components were added, removed or replaced were recorded as failures. Eighty-one revisions were exchange arthroplasties, eight attempted arthrodeses and one an above-the-knee amputation. Survival rates were calculated with a life table technique. The cumulative 5-year survival rate was 76 per cent for tibial hemiprostheses, 78 per cent for unicompartment prostheses, 100 per cent for tricompartment prostheses, 87 per cent for stabilized prostheses and 84 per cent for hinge prostheses. Continuous deterioration was observed in the tibial hemiprostheses. The improved surgical technique, with guide instruments and release procedures for better alignment and stability, and to some extent the improved prosthetic design may explain the good early results with tricompartment prostheses.

Fracture of the knee endoprosthesis. Report of three cases of tibial component failure.

Three cases of total knee replacement, in which the polyethylene tibial component was fractured, are presented. Two were Attenborough prostheses and the third was a Townley prosthesis. In all cases there were radiographic signs of loosening before the fracture occurred. They were all successfully reoperated with an arthrodesis, using the long Küntscher nail technique.

Prediction of long-term outcome of tibial osteotomy in medial gonarthrosis.

To predict the long-term outcome after tibial osteotomy for medial gonarthrosis, multivariate statistical techniques were used and prognostic equations were defined. A comparison between different evaluation systems was also performed. Clinical and radiographic data from 81 patients followed up for more than 7 years were used. Twenty-eight preoperative variables were analysed in relation to the outcome at 7 years with the multivariate procedures discriminant analysis and cluster analysis. Among the variables, knee flexion and walking capacity were found to be the most dominant factors. Excluding the undercorrected osteotomies, preoperative walking capacity was now the dominating variable for prediction. Seven years postoperatively only small differences were found between the evaluation criteria of pain relief, London Hospital score, and HSS score. The discriminant functions for the highest ranked evaluation criteria are given in the text, as are dendrograms showing the patterns of interdependence between the evaluation criteria. Thus it was possible to transform clinical entities into factors suitable for determination and calculation of postoperative evaluation. The most commonly used evaluation systems had very similar discriminant functions showing good agreement.

Surface replacement of the elbow in rheumatoid arthritis. Early results with the Wadsworth prosthesis.

Fifteen patients with rheumatoid arthritis had 19 elbow arthroplasties with the Wadsworth type of surface replacement prosthesis. After a follow-up period averaging 30 months, 11 patients with 15 elbow arthroplasties were entirely satisfied with their freedom from pain and range of movement. Radiologically, however, the humeral component was loose in 10 of the 19 elbows and the ulnar component in 5. Two patients had reoperation, one to remove a prosthesis for early deep infection and one to exchange a humeral component which was loose. The risk of mechanical loosening is reduced by accurate positioning of the humeral component, but there is a high potential for failure. Changes in the design of the prosthesis and better instrumentation for alignment of the components are desirable. Prosthetic replacement of the elbow should still be regarded as experimental.

The Lund drill guide. An instrument for repair or reconstruction of the cruciate ligaments.

A new drill for cruciate ligament repair is described. It is a modification of a French drill guide (Landanger). The guide allows for the possibilities of free adjustment in all planes and good stability during the drilling procedure. The instrument has been used in 22 patients with anterior cruciate ligament injuries and five patients with injuries to the posterior cruciate ligament. With this instrument it is sufficient with only an anterior approach for a posterior cruciate ligament repair. It is concluded that the Lund cruciate drill guide is simple and manoeuvrable for surgery of the ligaments of the knee joint. In all cases correct drilling was possible and in no instance the instrument has failed.

High tibial osteotomy: a seven-year clinical and radiographic follow-up.

A series of 107 knees were evaluated for mobility, stability and pain relief two and seven years after high tibial osteotomy for correction of deformity secondary to arthrosis; patients with rheumatoid arthritis were excluded from this series. Eighteen knees had lateral femorotibial arthrosis, or which only six had good results at seven year follow-up. As many as six knees required further surgery. Of the 89 knees with medial arthrosis, 45 had good results, 36 did not and the remaining eight required further surgery. Lasting pain relief was clearly associated with correction of the mechanical axis of the knee which was more difficult to achieve in severe stages of the disease. In 22 of the 24 corrected knees, the disease had not progressed further. Six of these showed radiographic signs of cartilage repair. By contrast, two-thirds of the undercorrected knees had further progress of the disease. The opposite compartment did not suffer from the increased load on the articular cartilage; only three overcorrected knees showed cartilage narrowing, and they were painless. High tibial osteotomy is a reliable method for definitive treatment of early medial type gonarthrosis provided that the radiographically defined mechanical axis is adequately corrected.

Tibial osteotomy in medial gonarthrosis. The importance of over-correction of varus deformity.

In a prospective series of 52 knees selected for high tibial osteotomy because of early medial arthrosis, special care was taken to obtain a final over-correction in valgus. The operative procedure and the pre- and post-operative radiographic examinations were standardized and the follow up was 1-3 years. 49 of the 52 knees had obtained a normal or over-corrected mechanical axis. 45 of these had improved painfree walking distance, and 31 were painfree. In 45 knees the arthrotic condition had not progressed, and in 5 of these there were signs of cartilage restitution. It is concluded that precise correction of medial gonarthrosis can be achieved, and this provides a rational basis for definitive treatment of early stages of this condition: for the majority an endoprosthesis operation should not be needed in the future.

Roentgen stereophotogrammetry in high tibial osteotomy for gonarthrosis.

In three cases operated with high tibial osteotomy for medial gonarthrosis the exact method of roentgen stereophotogrammetry with tantalum balls as bone markers (Selvik 1974) was used to study angular and translational movement in three dimensions at the operation and during the healing period. Tibial osteotomy caused angular and translational movements even in planes where correction was not intended, and the stereo technique revealed that stability was not present when knee mobilisation started. Correlation between the stereo values and conventional radiographic measurements were best in the frontal plane (root mean square value of discrepancies 1.3 degrees). Roentgen stereophotogrammetry gives superior information compared with the conventional radiographic technique, but it is concluded that the latter has sufficient accuracy for the clinical assessment of corrections in the frontal plane.

Technical accuracy in high tibial osteotomy for gonarthrosis.

A preoperative roentgenological analysis of the whole leg in the standing position is presented as an aid in high tibial osteotomy for medial osteoarthritis of the knee. This analysis provides information about the mechanical condition of the knee, the extent of the deformity and the exact size of the wedge of bone to be excised during the operation. The initial experience with this method is encouraging. In 66 osteotomies four-fifths had a postoperative correction within +/- 3 degrees of the predicted angle and after 1 year two-thirds were still within this range.

Results of surgical treatment for non-union after high tibial osteotomy in osteoarthritis of the knee.

In a series of 280 high tibial osteotomies performed for osteoarthritis of the knee between 1969 and 1975, there were ten cases of pseudarthrosis, an incidence of 3.6 per cent. These ten knees (and an additional two that were referred to us) were reoperated on. In most cases the pseudarthrosis was resected and stabilized with the Charnley transfixation-compression method. Other procedures involved resection without compression (one knee), compression blade-plate fixation, and arthroplasty with a hinge endoprosthesis. All osteotomies healed eventually with the knee in satisfactory position. In spite of the initial non-union and repeated operation, all twelve patients eventually had satisfactory correction of the preosteotomy deformity, and none had a loss in walking ability. All but two patients had freedom from pain. We concluded that patients with non-union following high tibial osteotomy for osteoarthritis of the knee should undergo resection of the pseudarthrosis and transfixation compression as the treatment of choice. Endoprosthetic replacement then can be used as a salvage procedure if it is needed.