Recovery after stabilising surgery for 'flail chest'.

BACKGROUND/PURPOSE: There is a lack of knowledge on respiratory and physical function, mobility and pain following stabilising surgery for 'flail chest'. The purpose of this study was, therefore, to evaluate pain, respiratory function, range of motion and physical function/activity 3 and 6 months after stabilising surgery in patients with 'flail chest' due to trauma. METHOD: Twenty-four patients diagnosed with 'flail chest' were, 3 and 6 months after the trauma, measured with regard to remaining pain, lung volume, breathing movements, and range of motion in the rib cage and thoracic spine. Physical function and level of physical activity were also estimated. RESULTS: Approximately 50 % of the patients had remaining pain after 3 months and 35 % had remaining pain after 6 months. Vital capacity was significantly decreased after 3 and 6 months compared to predicted values: >83 % after 3 months and >86 % after 6 months. There were no significant differences between the injured versus non-injured side in breathing movements, nor between the values of the range of motion between the two test occasions. The results of physical function showed mild to moderate disability 3 months after surgery and some or mild disability at 6 months. The patients were active, performing moderate exercise 1-2 h/week or light physical activities more than 4 h/week at 3 and 6 months. CONCLUSIONS: Patients who had undergone stabilising surgery due to 'flail chest' showed decreased range of motion 3 and 6 months after surgery. Despite decreased range of motion and remaining pain, the breathing movements are synchronic.

Charnley cups retained during revision of the femoral component: repeated clinical and radiographic observations of 49 cups for 7-15 years.

This article concerns 49 consecutive polyethylene cups retained in cemented first revisions of the femoral component and evaluated on several occasions 7-15 years after the index operation. At the last follow-up 5 cups were revised, 3 were radiographically loose, 1 was revised because of recurrent dislocation and 1 stable cup was revised because the surgeon wished to use a 28 mm head. Moreover, 1 unrevised cup was radiographically loose. This corresponded to a mechanical failure rate of 0.1 (5/49) and revision rate of 0.1 (4/49). 3 cups which were radiographically loose (100% radiolucency) had not been revised when the stem was exchanged. If these cups were excluded, the revision rate would have dropped to 0.02 (1/46) and the mechanical failure rate to 0.04 (2/46). This indicates the importance of careful preoperative radiographic evaluation on both AP and lateral views. Progression of radiolucent lines always occurred as an increase in extension from the periphery to the central region of the interface. In conclusion, Charnley cups with non-circumferential radiolucent lines and little, if any, wear can be retained without compromising the longevity of the implant. However, it should be stressed that this conclusion is based on a patient population in which four-fifths of the patients at the index operation were 65 years of age or older.

Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment.

In a prospective, randomised, multicentre study, 112 patients (99 men and 13 women, aged between 21 and 63 years) with acute, complete rupture of tendo Achillis were allocated either to surgical treatment followed by early functional rehabilitation, using a brace, or to non-surgical treatment, with plaster splintage for eight weeks. The period of follow-up was for two years. Evaluation was undertaken by independent observers and comprised interviews, clinical measurements, isokinetic muscle performance tests, heel-raise tests and an overall outcome score. The rate of rerupture was 20.8% after non-surgical and 1.7% after surgical treatment (p < 0.001). Surgical and non-surgical treatment produced equally good functional results if complications were avoided. However, the rate of rerupture after non-surgical treatment was unacceptably high.

The influence of fracture etiology and type on fracture healing: a review of 104 consecutive tibial shaft fractures.

This study was conducted to determine retrospectively the factors which influence fracture healing and risk for nonunion in patients with tibial shaft fractures. One hundred consecutive patients with 104 tibial shaft fractures and a mean age of 40 (14-85) years were reviewed. Fractures were classified according to the AO classification system. There were 22 open fractures and 52 comminuted fractures. Thirty-eight fractures were caused by high-energy trauma. Fracture pattern, soft-tissue condition, level of energy of the trauma, malalignment, and treatment methods were identified. The influence of these factors on the time of hospital stay and sick-leave, delayed union, and nonunion were calculated. Normal healing occurred in 61 fractures with a mean healing time of 17 weeks, delayed union in 27 with a mean of 35 weeks, and nonunion in 16 with a mean of 69 weeks. The relative risk of developing nonunion in open fractures was 8.2 (CI = 2.9-10.5) and 2.9 (CI = 1.2-3.2) in fractures exposed to high-energy trauma. This study showed that the soft-tissue condition and level of trauma energy are good predictors for the development of complications. Considering these risk factors at an early stage in the planning of treatment might reduce the risk of nonunion. ergy level of the trauma, fracture comminution, initial fracture displacement, treatment method, contamination, and associated injuries will influence fracture healing. Conservative treatment has in general been recommended for undisplaced closed or grade I open fractures caused by low-energy trauma [15, 18, 21]. However, conservative treatment of a tibial shaft fracture means immobilization of the lower leg for a long period of time, especially if healing is delayed. Thus, it is important to consider the risk of healing complications when planning the appropriate treatment method in the early stage after the injury. The purpose of this study was to analyze complications such as delayed union and nonunion and to identify factors which affect the healing of tibial shaft fractures.

Bone debridement and limb lengthening in type III open tibial shaft fractures: no infection or nonunion in 9 patients.

We retrospectively reviewed a consecutive series of 9 patients with tibial shaft fractures and extensive soft tissue damage, who had completed treatment by means of bone resection and distraction. 4 patients had type IIIB fractures and 5 type IIIC. The median follow-up time after bone resection was 27 (12-43) months. All patients were treated with debridement of devitalized soft tissue and resection of dead bone at the fracture site. The median bone shortening was 4 (3-9) cm. Equal limb-length was restored by proximal corticotomy and lengthening. A free vascular flap in 5 patients and a local flap in 4 patients corrected the soft tissue loss. All soft tissue transfers were successful, except in 1 case, which healed after a new free flap was made. The median union time of the fracture was 8 (4.5-28) months from the injury and 7 (3-10) months from the time of bone resection. There were no deep infections or nonunions and no secondary amputations. This series shows that bone debridement and limb lengthening, with a multidisciplinary approach, is often successful in salvaging limbs at high risk of amputation.

Salvaged limbs after tibial shaft fractures with extensive soft-tissue injury: a biopsychosocial function analysis.

BACKGROUND: The purpose of this study was to perform a biopsychosocial function analysis of the outcome in patients with a salvaged leg after tibial shaft fractures associated with extensive soft-tissue injury. METHODS: A retrospective review of 18 consecutive patients with tibial shaft fractures and extensive soft-tissue damage with a mean Injury Severity Score of 31 was undertaken. All patients were assessed for their physical function, psychological status, and general function. RESULTS: The range of motion and torque of the ankle joint were severely affected. The knee joint was affected, but only with regard to the torque during concentric muscular activities. Nottingham Health Profile scores showed that the general and social function for these patients were significantly affected. Five of 18 patients suffered from depression. CONCLUSION: Salvage procedures should be advocated if possible, but careful selection of patients on the basis of mental and social factors is crucial for the outcome.

Postural control and torque of the knee joint after healed tibial shaft fracture.

Muscular atrophy occurs as a consequence of trauma and immobilisation. This cohort comparison study was conducted to evaluate the limb function after healed tibial shaft fractures, which were treated by casting versus nailing. Balance (as centre of pressure) and muscle strength (as torque of the knee joint during knee extension) have been measured in 27 patients with tibial shaft fractures with a mean age of 39 (19-73) years, 1 year after fracture healing. Fourteen patients were treated by intramedullary nailing 'nailed group' and 13 by plaster cast with or without minimal internal fixation 'casted group'. Centre of pressure was measured on a force platform. Knee extension torque was measured during isometric and concentric muscle actions by an isokinetic dynamometer. Centre of pressure tended to be more towards the uninjured leg in patients who had been treated by plaster cast (P<0.05). Side-to-side differences for isometric torque were significantly higher within the casted group (P<0.05). Patients with tibial shaft fractures treated by intramedullary nailing showed better postural control, one-leg standing test, and side-to-side differences for isometric muscle strength compared with patients treated by cast. Therefore, we recommend intramedullary nailing as a better method of treatment for tibial shaft fractures, with regard to recovery of muscle function.

Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients.

Of 53 patients with unilateral, displaced and closed or grade 1 open tibial shaft fractures, 27 patients (group I) were randomized to treatment with an intramedullary nail and 26 patients (group II) to treatment with a plaster cast. 12 fractures in the latter group were considered stable enough for treatment with only a cast (group IIa), while 14 fractures in group II showed redisplacement during reduction under anesthesia or at 1 week follow-up. Therefore, these fractures were stabilized with cerclage or screws (group IIb), which was a prerequisite for continuing cast treatment. The mean time-to-union was 19 weeks for group I, and 25 weeks for group II. 6 patients in group I and 16 in group II had delayed union. The Nottingham Health Profile index scores on physical mobility, social isolation, work ability, and sexual life were significantly better in group I than in group II at 3 months after injury. Delayed union, malunion, and restricted range of motion at the ankle joint were common complications when these fractures were treated with a cast. We recommend intramedullary nailing for these fractures.

Reduced bone mineral content in adult patients with growth hormone deficiency.

Bone mineral content was measured in a follow-up study of adult patients with hypopituitarism and growth hormone deficiency. There were 95 patients (59 males, mean age 54.0 years, range 21-74 years; 36 females, mean age 53.5 years, range 31-73 years). Routine replacement therapy with cortisone acetate and L-thyroxine was given. All males that were gonadal deficient were on proper testosterone therapy, except in four patients who were treated separately. Bone mineral content (g/cm) was measured using dual-photon absorptiometry in the third lumbar vertebra. Bone mineral content in the patients was compared with a control population (N = 413, 25-74 years of age). Bone mineral content was significantly lower in males (N = 55, p < 0.05) compared with controls. In females, bone mineral content was significantly lower both among the subjects with untreated gonadal deficiency (p < 0.001) and among those with treated gonadal deficiency and normal premenopausal gonadal function (p < 0.005) compared with controls. To summarize, patients with hypopituitarism on routine replacement therapy but not growth hormone have a lower bone mineral content than the controls. The reduced bone mineral content might be a result of untreated growth hormone deficiency.

Accuracy, precision, and homogeneity effects in the determination of the bone mineral content with dual photon absorptiometry in the heel bone.

In this work the distribution of bone mineral content (BMC) in the calcaneus has been studied by means of dual photon absorptiometry. The bone mineral content determined according to the described method is corrected for the amount of fat and lean soft tissue in the path of the radiation beam. It is found that the bone mineral content shows a large variation in the calcaneus. There does, however, exists a homogeneous region in the central part of the calcaneus. The in vitro precision of the technique has been determined to be 1.02%, and the in vivo precision has been found to be 2.8%. The correlation coefficient between ashed bone mass and measured BMC value was 0.97.

Clinical assessment of rheumatic diseases using viscoelastic parameters for synovial fluid.

For the first time it is clearly exhibited that synovial fluid (SF) is thixotropic. Although no hysteresis loops were observed for SF, not even at high shear rates, thixotropy may be exhibited by measuring the rate of recovery after extensive shearing. The rebuilding of the structure in a small-amplitude oscillatory state following the high-shear-rate state reveals the thixotropic behaviour. Five different viscoelastic parameters for various synovial fluids (SF) were obtained using oscillatory rheometry. It was also shown that for SF in the low frequency range, corresponding to a knee joint almost at rest, the shear loss modulus G" is greater than the shear storage modulus G', since the system is allowed to dissipate energy at rest. However, with movement, G' increases and eventually becomes greater than G" at a characteristic frequency above which the system has insufficient time to dissipate energy and hence responds as an elastic body. This functional behaviour, characteristic for normal SF, broke down in the SF of rheumatoid arthritis. It was also absent in the SF of knee joints with meniscus lesions and ligament defects.

Mineral content and strength of lumbar vertebrae. A cadaver study.

Fifty-two cadaveric spine-motion segments were tested in compression alone and in combined compression-flexion to determine whether the compressive strength of lumbar vertebrae varied with the direction of the applied load, that is, whether similar relationships existed between the compressive strength and the amount of bone mineral depending on the direction of the loading. The bone mineral content (BMC) ranged between 1.6 and 5.8 g/cm and the ultimate strength between 810 and 10,090 N. The BMC of the motion segments was correlated with their strength irrespective of degree of flexion during testing (0-15 degrees). For compression-flexion within physiologic limits, the first part of the motion segment to fail was, with few exceptions, the end plate and the adjacent spongy bone.

Low back pain among retired wrestlers and heavyweight lifters.

The lifetime incidence and prevalence of low back pain among 32 retired wrestlers (ages 39 to 62 years) and 13 retired heavyweight lifters (ages 40 to 61 years) were evaluated and compared to the corresponding results in a cross-sectional study of 716 men (ages 40 to 47 years). The radiologic findings and the findings upon physical examination in the athletes were compared to the findings in another study of normal, active, similarly aged men who were sampled at random. The lifetime incidence and prevalence of low back pain was higher among the wrestlers (59%) compared with both the lifters (23%) and the control group (31%). The tolerance for backache seemed to be higher among the athletes than the controls. A higher frequency of old fractures was found among the wrestlers. The athletes with fractures had a higher frequency of low back pain. A significant decrease in disk height was found among the lifters.

The loads on the lumbar spine during extreme weight lifting.

The load on the lumbar spine was calculated in eight power lifters when they executed an extremely heavy lift. The calculated load on L3 as well as the total load lifted during training in the last year were related to the bone mineral content (BMC) in the L3 as determined with dual photon absorptiometry. The loads on L3 in the lifters ranged between 18.8 and 36.4 kN. The BMC values were extremely high and closely correlated to the amount of weight lifted during training (r2 = 0.82). The study showed that intensive training will increase the BMC to an extent that the spine can tolerate extraordinary loads.