Drainage is of no use in primary uncomplicated cemented hip and knee arthroplasty for osteoarthritis: a prospective randomized study.

In a prospective, randomized study, 58 patients with primary cemented hip arthroplasty and 39 patients with primary cemented knee arthroplasty were divided into groups with postoperative closed-suction drainage and without drainage. There was no difference in healing of the wounds, postoperative blood transfusions, complications, or range of motion. Although there was more soaked dressing requiring reinforcements in the groups without drainage, as a result of this study, we no longer use drains in uncomplicated cemented primary hip and knee arthroplasties for osteoarthritis.

Treatment of subcapital fractures of the fifth metacarpal bone: a prospective randomised comparison between functional treatment and reposition and splinting.

We did a prospective study to compare the results of treatment of subcapital fractures of the fifth metacarpal bone by closed reduction and splinting or by functional treatment. Twenty-nine consecutive patients were randomly divided into the two treatment groups (functional n = 14, and reposition and splinting n = 15). The results of treatment were satisfactory in both groups. Functionally treated patients recovered their grip force and range of movement of the affected hand a little sooner. All fractures in both groups had united within three months. There were no complications. We conclude that subcapital fractures of the fifth metacarpal bone can successfully be treated without closed reduction and splinting.

Postoperative discitis: outcome and late magnetic resonance image evaluation of ten patients.

BACKGROUND AND AIMS: MRI has proven to be the most effective method for demonstrating suspected postoperative discitis. The prognosis of discitis varies markedly in different series. The purpose of this study was to analyze the clinical outcome and late MRI findings of the patients with postoperative discitis. MATERIAL AND METHODS: The medical records of ten patients with discitis and of ten patients without infectious findings following lumbar discectomy in 1993 to 1995 were reviewed. A clinical follow-up investigation with a detailed questionnaire and MRI was performed. Without knowledge of the clinical history, a radiologist selected the cases of discitis based on evaluation of the MRI pictures, and thereafter after a combined analysis of preoperative CT scans and of the MRI pictures. RESULTS: The follow-up MRI demonstrated characteristic findings in every discitis case. However, similar changes were seen in four cases of the control group. The discitis group had more symptoms, a longer sick leave and less return to previous occupation than the control group. CONCLUSION: As a late examination, MRI is insufficient in itself for diagnosis of earlier discitis. Postoperative discitis lengthens the sick leave markedly. Patients with postoperative discitis are rarely capable to return to a physically strenuous work. Every effort, including antibiotic prophylaxis, should be undertaken to reduce the risk of this serious complication.

Autoarthroplasty of knee cartilage defects by osteoperiosteal grafts.

Five fresh osteochondral fractures of the knee, which could not be fixed because of extensive fragmentation, were treated by excision of the fragments and reconstruction of the joint surface defect by an autogenous osteoperiosteal graft. The procedure was also used for joint surface reconstruction in sclerotic osteochondritis of the femoral condyle (nine knees) and grave patellofemoral chondromalacia (three knees). Plaster cast immobilization for 3 weeks was used in the two early cases. In all other cases, we employed a passive motion apparatus for 2 days postoperatively, followed by active mobilization in a knee brace with extension-flexion 30 to 90 degrees (femoral condyle reconstruction) or 0 to 45 degrees (patellar reconstruction). Gradual free movements were started 3 weeks postoperatively. The results after 1.5 to 6.5 years were satisfactory in all but one case. One arthroscopic removal of the loose graft was performed, as were two arthroscopic graft margin shavings. Three other reoperations were unrelated to the osteoperiosteal reconstruction. It appears that periosteal reconstruction should be considered in local osteochondral lesions, where excision of the injured cartilage is mandatory. The results were best in fresh trauma cases and younger people.

Outcome and clinical signs of arthroscopically graded patellar chondromalacia with or without lateral release.

In a follow-up study of 67 patients with an arthroscopically diagnosed patellar chondromalacia, we compared the results of plain conservative treatment with those after an open lateral retinacular release. The mean follow-up was 35 months. In Grade I chondromalacia the lateral release did not affect the result, which was in all cases good or excellent. In Grade II to IV chondromalacia the lateral release appeared beneficial, although the difference did not reach statistical significance. We also examined the validity of three clinical signs in arthroscopically verified patellar chondromalacia. Patellar inhibition and tracking tests were clearly more sensitive than the lateral apprehension test, which often gave a false negative result. If the patellar inhibition test is positive and a Grade II to IV chondromalacia of the patella is found at arthroscopy, lateral release should be considered among other procedures, like patellar shaving or patellar resurfacing.

Compression-staple fixation for fractures, non-unions, and delayed unions of the carpal scaphoid.

We used the Richards scaphoid compression staple for operative fixation in a total of twenty-five patients who had a fracture of the carpal scaphoid: sixteen whom we reported on previously and nine whom we are reporting on for the first time here. In the current series, we extended the application of the method to fresh, unstable fractures (two patients) and treated an additional seven patients who had a non-union or delayed union. The procedure was simple, and no operative complications were encountered. Both patients who had a fresh fracture had a satisfactory result. Of the other twenty-three patients, only two had a result that was not satisfactory. One patient had a persistent non-union. Three patients had doubtful radiographic evidence of a persistent non-union; however, all three had a good result clinically, and only one had moderate loss of function. Although the over-all results were good, there was some worsening of the clinical results on long-term follow-up compared with those that we reported earlier. This deterioration probably was due to secondary degenerative changes in the articular surfaces.

Factors affecting survival of patients with hip fractures.

The preoperative findings of 111 patients after 117 fractures of the proximal femur were recorded retrospectively. Data on survival, present type of residence and ambulatory status were analyzed. After age and sex, the presence of dementia, renal insufficiency and cardiac failure seemed to be the most important factors affecting the outcome. A full preoperative evaluation of patients with a proximal femoral fracture is needed to identify those at risk. This evaluation may help in the selection of the operative procedure.

Metastatic fractures of long bones.

Forty-two patients with a total of 52 metastatic fractures of long bones were analysed retrospectively with regard to the type of treatment, complications, general mobility and survival. Endoprosthetic replacement appeared to be better than osteosynthesis in the proximal femur, and this method should also be considered in pathological fractures of the distal femur. Nailing is indicated in fractures of the shafts of long bones in the lower limb, and also in the humerus. Osteosynthesis with a plate has only limited indications. Cement should be added to an osteosynthesis or replacement of a pathological fracture in order to achieve immediate stability. On the whole, the life expectancy of these patients has improved; five in our series lived for more than 6 years after the treatment of their metastases. The method of surgical treatment therefore needs more consideration.

The late outcome of femoral neck fractures.

The late outcome of 562 consecutive femoral neck fractures is presented; 396 were treated with a Thompson hemiarthroplasty, 121 by internal fixation, 4 by primary total hip replacement, and 41 were treated conservatively. Mortality during the first 30 days was 5%. The incidence of primary and secondary local complications after osteosynthesis was 25%. Further operations were carried out in 10% of the hemiarthroplasties. Seventy-eight patients were evaluated clinically and radiologically 10 years after this operation; 24 had been converted to total hip replacements, and in 23 of the remaining 54 the prosthesis appeared loose on radiographs. There was severe protrusion of the metal head in 25 cases. The clinical result was excellent or good in only 17 of 78 cases. We conclude that osteosynthesis or total hip replacement, rather than a Thompson hemiarthroplasty, should be considered for the treatment of femoral neck fractures if the patient is active and appears to have a life expectancy of several years.

Late treatment of scaphoid fractures by bone grafting and compression staple osteosynthesis.

Scaphoid nonunions and delayed unions still offer a difficult challenge. In 15 of 16 cases it was possible to achieve a secure and lasting union by using a compression staple and a bone graft. The subjective and objective clinical evaluation also showed similar favorable results. This modification of the Russe operation is recommended as a relatively simple procedure with good results and minimal need for immobilization.

Resection of large tumors of the anterior pelvic ring while preserving functional stability of the hip.

Periacetabular tumors of the anterior pelvic ring often present difficult problems in diagnosis and treatment. The use of computed tomography is valuable. In cases of unquestionable malignancy, hemipelvectomy is the generally accepted treatment. In pelvic tumors of low grade or questionable malignancy, a local wide resection is indicated. Total acetabulectomy results in an unstable hip with marked leg shortening. Transacetabular anterior pelvic ring resection is recommended to preserve the superior part of the acetabular fossa. This procedure is illustrated in two men, 26 and 30 years of age, presenting with low or questionable malignancies.