Interpreting preoperative radiographs in displaced femoral neck fractures: observer variability in evaluating signs of poor outcome.

OBJECTIVE: To evaluate the reproducibility of four preoperative radiographic signs thought to be associated with negative prognosis in dislocated femoral neck fractures when treated with internal fixation. SETTING: University Hospital. DESIGN: Standard hip radiographs of ten patients with displaced subcapital femoral neck fractures were studied by five orthopaedic surgeons. The radiographs were studied twice; the second time on average 3 months after the first reading. Inter- and intra-observer reliability of four radiological parameters was estimated. RESULTS: Poor intra- and inter-observer reproducibility of all four signs tested was observed. CONCLUSIONS: The decision to treat an intracapsular femoral neck fracture with either prosthesis or internal fixation has to be based on other variables than the preoperative radiographic signs evaluated in this study.

The Scandinavian Sarcoma Group Skeletal Metastasis Register. Survival after surgery for bone metastases in the pelvis and extremities.

INTRODUCTION: The assessment of the prognosis for the individual patient is important for the choice of surgical treatment of skeletal metastases. In 1999 the Scandinavian Sarcoma Group (SSG) initiated the Skeletal Metastasis Register as a multicentric, prospective study to provide a scientific basis for treatment recommendations. To improve prognostication we analyzed the survival of patients with skeletal metastases surgically treated at 9 SSG centres. PATIENTS AND METHODS: 460 patients with an average age of 64 years underwent 501 operations for non-spinal skeletal metastases. 7% were operated for more than one metastasis. Carcinoma of the breast, prostate, kidney and lung were the dominating primary tumors. RESULTS: The survival rate was 0.4 at 1 year, 0.3 at 2 years and 0.2 at 3 years. Univariate analysis showed that survival was related to bone localization, skeletal metastatic load, presence of visceral metastases, Karnofsky performance score, primary tumor type, presence of a complete pathological fracture and preoperative hemoglobin content. Multivariate regression analysis showed that pathological fracture, visceral metastases, haemoglobin content < 7 mmol/L and lung cancer were negative prognostic factors for survival. Myeloma was the sole positive prognostic factor for survival.

Surgical margins, local recurrence and metastasis in soft tissue sarcomas: 559 surgically-treated patients from the Scandinavian Sarcoma Group Register.

The prognostic importance of surgical margins on local recurrence rates and metastasis-free survival (MFS) was studied in 559 patients with soft tissue sarcoma of the extremities and trunk wall. The patients were all surgically treated, but received no adjuvant treatment. The median follow-up for the survivors was 7.4 (range: 0.1 - 12.5) years. Independent prognostic factors for MFS were analysed by Cox models. The overall 5-year MFS was 0.72 (95% confidence intervals (CI) 0.68 - 0.76). High histopathological malignancy grade (relative risk (RR) 3.0; 95% CI 1.5 - 6.3) and an inadequate surgical margin (RR 2.9; 95% CI 1.8 - 4.6) were independent risk factors for local recurrence. High histopathological malignancy grade and large tumour size (> 7 cm) were the most important risk factors for metastasis. Local recurrence was associated with an increased risk of metastasis (RR 4. 4; 95% CI 2.9-6.8), but an inadequate surgical margin was not a risk factor for metastasis (RR 1.1; 95% CI 0.8-1.7). This study confirms that, as regards metastasis, tumour-related risk factors (malignancy grade and tumour size) are more important risk factors than treatment-related factors. Local recurrence was associated with an increased metastasis rate, whereas inadequate surgical margin was a risk factor for local recurrence but not for metastasis. Hence, the proposed causal association between local recurrence and metastasis is doubtful, and if it exists is a weak association.

Fibrosarcoma in children--a rare tumour with long-term survival even with advanced disease--a report of 3 cases.

Fibrosarcoma is a rare tumour in children. The potential of malignancy has been questioned. We present three cases of fibrosarcoma in children . The follow-up periods range from 10 to 37 years. The first patient had pulmonary metastases at the time of diagnosis in 1958. The primary tumour in fossa ischio-rectalis was resected in 1960. Lung metastases were resected in 1960 and 1989. Radiotherapy was given in 1992. He is still alive with metastases 37 years after the first manifestation of disease. The second patient had a primary tumour and several local recurrences in the mandible. He is alive without evidence of disease 4 years after resection of pulmonary metastases and 21 years after resection of the primary tumour. The third patient has no signs of recurrence or metastatic spread 10 years after a wide excision of subcutaneous tumours of the left upper arm. The cases demonstrate a special tumour-entity of low-grade malignancy, which show a good prognosis and a wide spectrum of biological behaviour.

[Swimming-induced asthma]. / Svømmeindusert astma.

Swimming is said to have low asthmogeneity especially when compared with other physical activities. Four young athletes who participated in heavy swimming exercise are reported as having symptoms of exercise-induced asthma (EIA). Three of them started to develop the symptoms after several years of training and had no former history of asthma. In the fourth, the asthma was diagnosed in childhood but the EIA-symptoms here exacerbated by swimming. All four experienced more symptoms when the air in the swimming pool was warm, or when there was a strong smell of chlorine. Two of the athletes reported having no symptoms when they swam in outdoor pools and had only minor symptoms, or none at all, when they did other formes of physical exercise, including running. In all four their swimming performance was hampered by their respiratory symptoms. Two of the swimmers improved when they inhaled steroids and adrenerg-beta 2 agonists, and continued their swimming carrier. The cases suggest that an irritant may provoke asthma symptoms in susceptible swimmers. Volatile compounds from chlorination of the pools are suspected as possible irritant agents.

[Quality assurance in an emergency department--what is it?]. / Kvalitetssikring i en akuttavdeling--hva er det?

To date, the medical profession has worked mainly on the improvement of medical treatment and has concentrated less on the methods used and the information given to patients and colleagues. The different aspects of quality in the daily routines are described, and some of these are used as examples of how a system for quality assurance can be developed. It is important that each department develop its own system of quality assurance adapted to local difficulties and different specialties.

Trochanteric fractures--a clinical and radiologic evaluation of McLaughlin, Ender, and Richard's osteosynthesis.

Four hundred and thirty femoral trochanteric fractures operated with nail-plate (McLaughlin), Ender, or sliding screw-plate (Richard) osteosynthesis were followed up radiographically and clinically. For each method of osteosynthesis the initial nail position was correlated to the occurrence of late mechanical complications. Unstable fractures were associated with a higher incidence of one or more clinical complications such as repeated surgery, post-operative death, or increased pain. For Ender osteosynthesis correlations were found between several mechanical and clinical complications, while for Richard's osteosynthesis mechanical complications were significantly correlated to repeated surgery only. McLaughlin and Ender osteosyntheses had a higher incidence of reoperations than Richard's osteosynthesis, whereas the mobility and ADL function were the same at 4 months.

Large intramuscular spindle-cell lipoma. With review of the literature. A case report.

A case of a large spindle-cell lipoma in an intramuscular (subfascial) localization is reported. The tumour occurred in a 58-year-old male patient and was localized subfascially in his left deltoid muscle. The tumour measured 20 X 8 X 8 cm; its weight was 780 grams. After initial biopsy, the tumour was extirpated. Microscopically, the tumour tissue consisted of mature fat cells and spindle-cell areas in varying amounts, constituting a typical appearance of a spindle-cell lipoma. There were no histological signs of malignancy. Especially, no areas of liposarcoma differentiation were detected. The patient is well, with no signs of recurrence, one and a half years after the operation. We have reviewed the literature on spindle-cell lipoma, and we believe this is the first example of this neoplasm to be reported in an intramuscular (subfascial) localization.

Trochanteric fractures. Classification and mechanical stability in McLaughlin, Ender and Richard osteosynthesis.

Four hundred and thirty trochanteric fractures operated upon with McLaughlin, Ender or Richard's osteosynthesis were divided into 6 different types based on their radiographic appearance before and immediately after reposition with special reference to the medial cortical support. A significant correlation was found between the fracture type and subsequent mechanical complications where types 1 and 2 gave less, and types 4 and 5 more complications. A comparison of the various osteosyntheses showed that Richard's had significantly fewer complications than either the Ender or McLaughlin types. For Richard's osteosynthesis alone no correlation to fracture type could be made because of the small number of complications in this group.

Open tibial fractures treated with Hoffmann external fixation.

Thirty-two open fractures of the tibial shaft were treated with external fixation between 1973 and 1981. Early amputation was necessary in one patient. In the remainder, including 14 with extensive soft-tissue lesions, wound healing was obtained within 18 weeks, and the median time until full weight bearing without pain was 32 weeks (range 8-60 weeks). Two deep infections healed during the observation period. Among 26 patients examined 1-9 years after the injury, the result was excellent in six, good in 11, fair in four, and poor in five patients (including the amputation). One fracture had not united during the observation period. Four poor results were due to the stiffness of the ankle and foot after compartment syndrome. In conclusion, alertness for early fasciotomy is necessary even in severe open tibial fractures. The external fixation should not be continued longer than the soft tissue and bone reconstruction make it necessary.

Bone metastasis. Prognosis, diagnosis and treatment.

Carcinoma of the breast, lung or prostate cause the majority of all bone metastases. Prolonged survival is common in patients with breast or prostate tumours. Different types of treatment may significantly increase the quality of life. Single-dose or fractionated radiation therapy may be effective, and 70 to 90 per cent of patients obtain partial or complete relief from pain. Surgery followed by irradiation is indicated in most patients with pathologic femur fractures. Immediate surgical treatment, either alone or combined with radiation therapy, may prevent paraparesis in patients with incipient cord compression. For neoplasms sensitive to systemic therapy such treatment should often be added to local treatment.

Supracondylar fracture of the humerus in children: review of closed and open reduction leading to a proposal for treatment.

Of 70 supracondylar fractures of the humerus in children, 25 were treated by open reduction and internal fixation, 24 by closed manipulation and plaster and 21 by plaster-of-Paris only. Three of the fractures were operated on because of suspected vascular injury (with or without neurological symptoms), another seven because of instability and/or extreme swelling and 15 after unsatisfactory closed reduction. Traction was used in 3 of the 24 patients treated by closed methods and among the other 21, three fractures had to be manipulated twice. Three to six years after the injury, 6 of the 25 patients operated on had reduced flexion-extension and/or deformity exceeding 10 degrees. Five patients treated by closed reduction had reduced movements or deformity exceeding 10 degrees and three patients with originally undisplaced fractures had deformity exceeding 10 degrees. In this study the most severe fractures were selected for operation but, in spite of this, the results were better than for fractures treated by closed reduction and plaster. Based on this and previous studies, a plan suitable for most departments is suggested for the treatment of this fracture.

Complications after trochanteric fractures. A comparison between Ender and nail-plate osteosynthesis.

Three hundred and forty-one trochanteric femoral fractures operated with intramedullary nailing (Ender) or nail-plate osteosynthesis (McLaughlin) were followed up for 4 months and reoperations were recorded at 18 months. Both methods had an unacceptably high frequency of complications, radiographically in one third and reoperations in one tenth of the total material. The greatest number of operative technical problems was encountered in the Ender group. The 4-month radiographic follow-up showed more complications in unstable than in stable fractures for both methods. In stable fractures, the Ender group had more radiographic complications. There was a slightly better walking capacity at 4 months and fewer reoperations at 18 months in the McLaughlin group.

Incidence and stability of trochanteric femoral fractures.

Sex, age and stability were recorded in 376 cases of trochanteric femoral fractures. In 168 cases the age and sex specific incidence was determined. When comparing our results with those in previous studies from the same region there was no increase that could not be related to age. This is in contrast to other reports from Scandinavia where investigators have found an increase in fracture incidence that could not be explained by the increasing number of old people. We, as others, have found a high proportion of unstable fractures. The unstable fractures did not occur more frequently in the oldest age groups.

Ultrasound in sciatica.

Investigation of the sagittal diameter of the spinal canal by ultrasound has shown a relative stenosis in patients with sciatica. In this study 12 patients who had recovered uneventfully after being operated on for herniated lumbar discs were found to have a broader spinal canal than 10 patients treated in the same way but still suffering from pain. Moreover, more difficulty was experienced investigating this latter group with the described "B-scan" technique. It is suggested that a preoperative ultrasound investigation would be able to indicate a narrow spinal canal and thereby reduce the number of disc operation failures.

Anteversion measurements in trochanteric fractures of the femur.

The anteversion of the femur was measured in trochanteric fractures operated upon with nail-plate or Ender osteosynthesis, and the results were compared with a normal material. A significant reduction in anteversion was found in the cases with Ender osteosynthesis as a possible explanation for the outward rotation of the operated limb commonly observed in these patients. No difference in anteversion was found between cases operated upon with conventional Ender technique, i.e. without anteversion of the nails, and those operated upon with a modified technique where the nails had been anteverted if considered appropriate at the operation.