Revision of the PCA unicompartmental knee. 52 arthrosis knees followed for 2-5 years.

We evaluated 52 unicompartmental PCA arthroplasties for primary (46) or secondary (6) arthrosis after 3 (2-5) years. Cementless fixation was used in 35 femoral and in 28 tibial components. There were indications for revision in 11 cases. Conversion to a total knee had been performed in 4 cases, and 1 tibial as well as 1 femoral component had been exchanged, mainly because of polyethylene wear with increasing deformity. 2 femoral components were loose and 1 had fractured.

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.

Results of elbow synovectomy in rheumatoid arthritis.

Synovectomy of the elbow was performed on 54 patients (70 elbows) with rheumatoid arthritis. The mean follow-up time was 7.5 years (range 1.5-22 years). Clinical evaluation showed marked relief of pain in 28 elbows (40%). In 27 cases (38.5%) the pain was moderate but still less than preoperatively. Severe pain was recorded in 15 cases (21.5%) at the time of check up. As to postoperative range of movement, the mean flexion are was 114.5 degrees and the mean rotation are 134.5 degrees. Latitudinal instability was recorded up to 5 degrees in 33 (47%) elbows, up to 10 degrees in 20 (28.5%), up to 15 degrees in 6 (8.5%), and more than 15 degrees in 11 (16%). The mean carrying angle was 10 degrees in valgus. Measurement of strength in flexion and extension showed a reduction of approximately 50% compared to age-matched healthy controls. Reoperations were performed in 10 elbows (14%); the interval between the primary synovectomy and second operation in these cases averaged 8 years.

Fibroblasts in synovitis in rheumatoid arthritis but not in noninflammatory synovial tissue in meniscus lesions express the carboxyterminal domain of procollagen type I.

Synovial tissue (ST) sections from patients with rheumatoid arthritis (RA) and meniscus lesions were stained using monoclonal antibodies against the carboxyterminal domain of human type I procollagen (alpha-pC) in avidin-biotin-peroxidase complex (ABC) staining. This gave a good signal-noise ratio and identified some synovial B-type lining cells and stromal fibroblasts in inflammatory RA ST but not in noninflammatory ST from patients with meniscus lesions. The authors' findings provide immunohistochemical evidence that the local fibroblasts in inflammatory ST in RA are activated, probably as a result of various humoral mediators produced in situ (by inflammatory mononuclear cells) in RA but not in normal noninflammatory ST.

The Neer II replacement for rheumatoid arthritis of the shoulder.

Thirty-eight patients had a Neer II replacement for rheumatoid arthritis of the shoulder. The average age at operation varied from 23 to 68 years. The average follow-up was 20.9 months. Forty shoulders were free of pain and function was reasonable in 21. Overall evaluation showed an excellent or satisfactory result in 15, 16, were acceptable and 10 poor. The most frequent radiological finding was upward subluxation which was present in 20 shoulders. An incomplete radiolucent zone was found around the glenoid component in 32% and around the humeral in 5%; there was no gross loosening.

Silicone rubber implant arthroplasty of the metacarpophalangeal joint in rheumatoid arthritis: a follow-up study of 32 patients.

A retrospective analysis of silicone rubber implant arthroplasty of the metacarpophalangeal joint in 32 patients with rheumatoid arthritis is reported. One hundred seven implants were followed in 37 hands for an average of 44 1/2 (12 to 120) months. Active motion of the metacarpophalangeal joint averaged 34 degrees, with a mean extension deficit of 7 degrees and a mean flexion 41 degrees. Ulnar deviation recurred to more than 10 degrees in 33 of 107 fingers (31%). Fracture of the spacer was confirmed in four joints (4%). One fracture of the proximal phalanx and one of the metacarpal head had occurred. Bone resorption around the stem or a hinge and migration of the implant were found in 26 (24%) fingers. Patient satisfaction was high; 27 patients experienced significant pain relief, the functioning of 31 hands (84%) was improved, and 28 patients (32 hands) thought that the cosmetic appearance of the hand was improved.

Arthrodesis of the wrist by internal fixation in rheumatoid arthritis: a follow-up study of forty-five consecutive cases.

Between 1972 and 1981, 59 wrists of 44 patients destroyed by rheumatoid arthritis were arthrodesed by internal fixation with a Rush pin. This study comprises 45 wrists of 38 surviving patients--nine men and 29 women, aged 20 to 72 years. The follow-up time ranged from 1 to 11 years with a mean of 3.9 years. The surgical technique used in this study is simple and safe, and a good position of the wrist in both frontal and lateral projections can easily be achieved. The Rush pin is passed down the third metacarpal and into the radius. It stabilizes the wrist adequately. All the wrists operated on obtained a strong bony fusion of the radiocarpal joint. The complication rate was low. Five of 45 Rush pins were removed because the subcutaneously located distal tip between the metacarpals irritated tendons and skin. In one male patient a thin Rush pin broke and a pseudoarthrosis of the intercarpal joints developed; there was, however, no need to remove the pin.

Fever, C-reactive protein, and erythrocyte sedimentation rate in monitoring recovery from septic arthritis: a preliminary study.

Body temperature, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were measured sequentially in nine children less than 11 years old during their recovery from culture-positive septic arthritis (SA). The measurements were compared with those of two other children who recovered without antibiotic therapy. A clinical investigation carried out several months after discharge suggested permanent recovery in all cases, including the spontaneously recovered patients. Defervescence and normalization of the primarily elevated CRP and ESR values occurred in a similar manner in both groups. On average, fever lasted 5 days, CRP level decreased below 20 mg/L in 7 days, and ESR reached a value of less than or equal to 20-25 mm/h in 22 days. The normalization time of ESR differed highly significantly (p less than 0.001) both from the duration of fever and from the normalization time of CRP level. Because CRP behaved in a similar manner in both the medicated and the nonmedicated groups, its normalization suggests true extinction of the active inflammatory process. If so, CRP level may be of benefit in monitoring the duration of antibiotic therapy for SA, but the hypothesis has to be confirmed in a larger clinical trial.

A comparative study of osteomyelitis and purulent arthritis with special reference to aetiology and recovery.

We analysed the records of 44 paediatric cases of acute haematogenous osteomyelitis (age 0-14 years) and 25 cases of purulent arthritis (age 0-13 years). The annual incidences were 4.5 and less than two per 100,000 children, respectively. Bacteriologic diagnosis was achieved in 82% of the acute haematogenous osteomyelitis cases and in 40% of the acute purulent arthritis cases. Staphylococcus aureus was responsible for 70% of the proven acute haematogenous osteomyelitis and acute purulent arthritis cases combined, followed by streptococci (20%) and Haemophilus influenzae (7%), which caused only acute purulent arthritis. Acute haematogenous osteomyelitis was localized in the femur in 41% of the cases and acute purulent arthritis in the knee joint in 76%. Surgery (in most cases drilling, fenestration or arthrotomy) was performed on 82% of the acute haematogenous osteomyelitis and on 32% of the acute purulent arthritis patients. Although six of the acute haematogenous osteomyelitis patients (but none of the acute purulent arthritis patients) underwent surgery for a second time, permanent damage, which was functionally non-significant, developed in only 14%. No sequelae were found in the acute purulent arthritis group. The average duration of antimicrobial therapy was 44 days in the acute haematogenous osteomyelitis group and 29 days in the acute purulent arthritis group. The prognosis for the children was similar, irrespective of whether the drugs used were staphylococcal penicillins, ampicillin, lincomycin or clindamycin.

Lateral ligament injury of the ankle in children. Follow-up results of primary surgical treatment.

Among 40 acutely injured ankles in children, surgery revealed a cartilaginous and/or bony fragment in 19, and an isolated rupture of the anterior talo-fibular ligament without any lesion of the bone or cartilage in another 17. In four ankles there was no ligament lesion. The lesions were surgically repaired. All ankles healed well and were painless and functionally stable at follow-up. In four ankles radiographs showed a small subfibular fragment, in which bony fusion had failed, but even these ankles were stable. Two other ankles gave a slightly positive sign in the clinical anterior drawer test as compared with the contralateral uninjured ankle, but there were no signs of functional instability nor were there any subjective complaints. Our results suggest that severe ankle sprains in children may cause isolated ruptures of the anterior talofibular ligament and frequently osteochondral lesions. We therefore advocate primary suture of ruptured lateral ligaments of the ankle in children.

BCG vaccination as a cause of osteomyelitis and subcutaneous abscess.

Ten patients with osteomyelitis and three with a subcutaneous abscess, all caused by BCG vaccination, are described. All patients were less than 3 years old and had as newborns been vaccinated intracutaneously in the left gluteal or hip area. Pain, limping, or a slightly tender subcutaneous induration were the primary symptoms. The sites of predilection of osteomyelitis were the metaphysis or epiphysis of the femur, these being affected in five out of 10 cases. All three subcutaneous abscesses were in the thoracic region. Prolonged (up to 30 months) combined tuberculostatic medication, in addition to appropriate surgical procedures, resulted in healing, but two cases of arthritis and two of secondary abscesses developed. In addition, sequestrectomy and two late operations, for coxa valga and hip subluxation, were deemed to be necessary. Radiographs showed femoral overgrowth of up to 1 cm in two symptomless patients three to seven years after the first discharge. We conclude that the benefits of BCG vaccination should be weighed against the risk of complications, especially in countries with a low incidence of tuberculosis.

Synovectomy of the wrist in rheumatoid arthritis and related diseases. A follow-up study of 97 consecutive cases.

Synovectomy of the wrist was done on 77 patients (97 wrists) during 1968-1981. The age of the patients at the time of operation ranged from 18 to 77 years, mean 44.9 yrs. Clinical and radiological follow-up examinations (90 wrists) or follow-up evaluation by questionnaire (7 wrists) were made by the authors in 1982. The mean length of the follow-up period was 8.5 years. Clinical symptoms of pain, swelling, restricted motion, instability and deformity of the wrist joint were evaluated and graded according to a special score. Radiological changes due to rheumatoid arthritis and osteoarthrosis were graded and analysed. Eight wrists were arthrodesed during the follow-up. Among the remaining wrists (89 cases) pain was absent or almost absent in 39%, was less than before the operation in 49% and was unchanged or worse in 12% of cases. The respective percentages for the presence of swelling were 47%, 36%, and 17%. The range of dorsiflexion was between 0 and 70 degrees, with an average of 27.9 degrees. The range of volar flexion was between 0 and 75 degrees, the mean being 28.2 degrees. The average ulnar and radial side motions were 12.9 degrees and 5.4 degrees, respectively. The radiological grading of RA remained about the same in 10 wrists and did not improve in a single wrist. In the other wrists the X-ray changes progressed. The results (patient's opinion) were subjectively good in 53%, fair in 32%, and poor in 15%.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute purulent arthritis in children.

Acute purulent arthritis (APA) in children is a rare disease. A series comprising 25 children with APA seen in 1960-79 was analysed with regard to clinical problems of diagnosis and treatment. The sex ratio of boys to girls was 2.5:1. The knee joint was most commonly affected (76% of the cases). The other joints affected were the hip (16%), ankle (4%), and elbow (4%), 56% of the patients were 1-2 yr old at the onset of the disease. A bacterial etiology was established in 44% of cases; a positive culture in 36%. Staphylococcus aureus, Haemophilus influenzae, streptococci, and pneumococci were isolated. All but 2 patients received antimicrobial therapy; the duration of therapy averaged 35 days. Seven patients were treated operatively. The usual procedure was arthrotomy, and closed irrigation was performed in 2 cases only. The end result was good in all cases. There were no fatalities.

Sprained ankle in children. A clinical follow-up study of 90 children treated conservatively and by surgery.

The study concerns 90 ankle injuries with lateral sprains, in children aged 5 to 14 years. 50 ankles treated non-operatively during 1978 were examined clinically and radiologically 14 to 24 months (mean 18 months) after the injury. Those patients who still had complaints were examined by questionnaire in October 1982, about four years after the injury. 21 patients (42%) had symptoms of disability at the first follow-up examination, and in 4 of these 21 ankles had to be operated on later because of functional instability and pain. Five others which had been treated conservatively, continued to have symptoms of functional instability four years after the injury, whereas the other 12 had healed and were symptomless. In 40 acutely injured ankles, surgery revealed an avulsion fragment in 19, and an isolated rupture of the anterior talo-fibular ligament without any lesion of the bone or cartilage in another 17. Ankles treated operatively healed well and the patients were symptom free at follow-up 6 to 21 months (mean 9 months) postoperatively. Our results suggest that lesions of the anterior talo-fibular ligament are surprisingly common in children. Primary repair of the ligament will ensure a symptomless and stable ankle joint.

Flexor tendon injury of the hand in children. A long-term follow-up study of 84 patients.

The treatment series comprised 96 children with flexor tendon injuries of the hand. Sixty-one per cent of the injuries were in no-man's land. About one half of the patients had tendon severances of the little or ring fingers. The flexor tendon was sutured in 57 hands (59%) and grafted in 37 hands (39%). Tendon transposition was performed in two hands (2%). A total of 84 children were reexamined after a mean follow-up of 8.5 years. Of 53 hands in which direct tendon sutures had been done, either as a primary, delayed or late procedure, results were good in 46 (86.8%), fair in five (9.4%) and poor in two (3.8%). Of 30 free tendon grafts performed on 29 patients, results were good in 14 fingers (46.7%), fair in 10 (33.3%) and poor in six (20%). We recommend primary suture of a divided profundus tendon at any level. A cut superficialis tendon in no-man's land should be excised, if the surgeon is not a skilled hand surgeon. In our experience suture of the flexor tendon, performed at any level, gives better results than grafting.

Peripheral nerve injuries of the hand in children. A follow-up study of 38 patients.

Thirty-eight children in whom a peripheral nerve injury of the hand had been repaired from 2 to 18 years earlier (mean 7.5 years) were examined. All repairs had been performed with the conventional technique with epineural sutures, and nearly all were primary neurorrhaphies. Sensory recovery was evaluated by using the two-point discrimination test (2 PD). The results were considered good if the 2 PD value was less than 6 mm and poor if this value was more than 15 mm. Of the 20 repairs of an ulnar or median nerve, or both, results were good in eight (40%), fair in 10 (50%) and poor in two (10%). Of the 18 digital nerve repairs, results were good in 14 (77.8%) and fair in four. The results in this series are better than results reported for adults series.