Spectacles may improve reading speed in children with hyperopia.

PURPOSE: The purpose of this study was to investigate the role of (hyperopic or myopic) spectacle correction in reading speed of 9- to 10-year-old children. METHODS: Subjects were recruited at their schools. Initial selection was based on reduced distance acuity and/or a positive blur test. Final inclusion depended on cycloplegic refraction. Forty-three myopes were prescribed glasses. Sixty-five hyperopes were randomized to three groups: (1) no glasses, (2) +0.5DS for both eyes, and (3) full correction. Before and 4 to 6 months after prescription of glasses, reading speed was tested: One-Minute Test (reading speed of genuine words) and the Klepel (reading speed of nonwords). Data for this second reading test were obtained in 34 myopes and 48 hyperopes. RESULTS: At baseline, myopes had about 11% higher One-Minute scores (p = 0.005) and about 9% higher Klepel scores (p = 0.066) than hyperopes. At follow-up, the hyperopia-full correction group improved its One-Minute score by about 13% more than both the no-glasses group (p = 0.012) and +0.5DS group (p = 0.019). Spectacles did not, or only slightly, improve reading scores of myopes (One-Minute scores, p = 0.068; Klepel scores, p = 0.021). CONCLUSIONS: Correction of hyperopia may increase speed of reading (as reflected by the One-Minute score). The fact that reading speed of nonwords does not increase after correction suggests that hyperopia affects speed of recognition but not decoding per se.

Hip fracture implants increase serum metal levels.

OBJECTIVE: Hip fractures are disabling accidents in the elderly. The purpose of this prospective study was to investigate systemic exposure to metals from hip implants used for fracture fixation. MATERIAL AND METHODS: Serum levels of Cr, Ni and Mo in patients with compression hip screws (n = 22) or cervical fracture screws (n = 23) were measured by inductively coupled plasma mass spectrometry. Blood samples were collected before surgery and at 3 and 12 months postoperatively. RESULTS: At 3 months, patients with compression hip screws showed higher concentrations of Cr and Ni than did those with cervical screws. Both types of screws led to a 2-fold increase in serum Mo, which was not expected for the freestanding cervical screws. After 12 months, the levels had decreased, but the compression hip screw was still associated with higher values for Cr and Mo. CONCLUSIONS: The difference between the screws is most likely due to the potential for fretting and crevice corrosion between components in the compression hip screws. The apparent short-term systemic elevation of stainless steel elements in patients with hip screws does not support routine removal of asymptomatic hip fracture implants.

Nickel contamination from an intravenous catheter used for infusion.

At the outset of a clinical research project involving metal analyses on patients receiving metal devices in conjunction with hip fractures, unexpected high concentrations of nickel were discovered in serum samples taken before surgery. The median nickel concentration in 30 patients was 4.6 microg/l (highest 19.5 microg/l), while reference values in non-exposed persons are reported to be 0.05-1.2 microg/l. The sampling and analyzing procedures were scrutinized without positive identification of the source of contamination. A review of all relevant procedures was then undertaken. It was identified that the nickel contamination originated from the intravenous catheter which was always put in place immediately after the patient's admission to the hospital, and thus before the blood sampling. Close inspection of the intravenous catheter revealed that it contained a nickel-plated brass funnel inside the hub of the device which released nickel into the Ringer-acetate passing through the catheter. The present catheter has been the standard device used at Haukeland University Hospital for the past 6 years. Patients have consequently been exposed to small amounts of nickel. The clinical relevance of the exposure cannot be determined. For the patients included in the research project, a metal-free alternative was used. These findings show that the quality and properties of everyday medical devices should be scrutinized, at least before being used for special purposes.

Long-term follow-up after primary repair of the anterior cruciate ligament: clinical and radiological evaluation 15-23 years postoperatively.

INTRODUCTION: We have previously reported results after 2-5 and 5-10 years follow-up of repair of acute anterior cruciate ligament (ACL) ruptures by suturing. Reports of results after more than 10 years are rare. MATERIALS AND METHODS: A total of 140 patients were operated on in the period 1975-1983 (age range 13-71 years, median 28 years) by the modified Palmer technique. Only 2 meniscus resections and 4 meniscectomies were performed at the primary operation; while 28 menisci were sutured. At follow-up,12 patients were dead. Eighteen patients (13%) underwent repeat operations for secondary instability. Of the remaining 110 patients, 81 appeared for follow-up. RESULTS: Only 6 secondary meniscus resections were performed, all in the group of 18 patients operated on again for instability. No secondary meniscus surgery was performed on the 81 patients who appeared for follow-up. The median Lysholm score was 88, and 58 of the 81 patients (71%) classified their total knee function as good or excellent. By KT-1000 testing, 33 (41%) patients had less than 3 mm anterior instability, 29 (36%) had 3-5 mm instability, and 17 (21%) had more than 5 mm. With 18 patients from the total of 128 living patients re-operated for instability, we estimate the rate of total failure of stability as 27%. Radiological osteoarthritis grade C was present in 8 operated and 2 control knees, while only 1 operated knee revealed osteoarthritis grade D. Thirty-four operated and 20 control knees had grade B. Osteoarthritis was correlated to more advanced age at injury, while correlation to function could not be proven. Radiographs were obtained of 61 patients at follow-up. CONCLUSIONS: Some 50% of patients had stable or slightly unstable knees, and 40% good or excellent function according to the Lysholm score. Re-operation for instability was more frequent in younger patients, while ostearthritis was more frequent in older patients. The rate of meniscus resection or extirpation was low. Open repair by suture is no longer recommended. Further research is indicated on the possible use of refixation of the ruptured ACL by arthroscopy.

Intramedullary nailing in humeral shaft fractures. Mechanical behavior in vitro after osteosynthesis with three different intramedullary nails.

The aim of this in vitro study was to compare the mechanical behavior of fixation by the Russell-Taylor nail with the more recent Polarus nail. Fixation with an experimental nail made from polyacetal polymer was also included in the study. Thirty humeri were fractured and randomized to receive one of the three nail types. A four-point nondestructive bending test was performed, as well as torsional testing to failure. The torsional test was designed to record the amount of 'play' (uncontrolled rotation) in the bone/implant construct. The Polarus nail gave higher rigidity of the nail/bone construct than the two other types. The Russell-Taylor nailing exhibited a high degree of 'play' (uncontrolled rotation). The polyacetal nails allowed a large elastic deformation before failure.

[Back pain--when both patients and physicians are in deep waters]. / Ryggsmerter--når så vel pasient som lege går i vannet.

BACKGROUND: Intraosseous pneumatocysts are rare and represent a benign condition. Such cysts can be an incidental finding described as a lytic process on plain X-rays. Computed tomography (CT) will confirm the diagnosis. Bone cysts filled with air are most frequently described in the iliac bone and in the sacrum, very rarely in the vertebrae or other bones. MATERIAL AND METHODS: This paper describes a patient that over a four to five-years period experienced relapses of rather strong lower back and hip pain of short duration during shallow water diving and ascent, and also during air travel. RESULTS: Plain X-rays of the lower spine and left hip (prescribed because of an earlier hip trauma) demonstrated a lytic process in the left iliac bone. CT of the pelvis confirmed the diagnosis of an intraosseous pneumatocyst in the left iliac bone. A mini-invasive procedure with CT-guided puncture under local anaesthesia and destruction of the cyst relieved the patient's symptoms. INTERPRETATION: The physician should consider rear causes of lower back pain in otherwise healthy patients. As demonstrated here, the causal treatment can sometimes be quite simple.

Dynamic traction for unstable fractures of the distal radius.

We have designed a flexible distracter through which dynamic traction is applied to fractures of the distal radius. The distraction is maintained during flexion and extension as well as radial and ulnar deviation. The results in 30 patients showed that the majority of the fractures maintained reduction during the period of dynamic traction. In several patients the radiological variables even improved during dynamic traction. The median radial shortening was 0 mm, the palmar angulation 7 degrees, and the radial inclination 23 degrees. Continuous dynamic traction applied to fractures of the distal radius did not lead to redisplacement of the fracture, and the overall functional results were good.

Lateral ligament injuries of the knee.

Between 1982 and 1994 28 patients were treated for acute lateral knee ligament injuries; 25 patients, with a median age of 25.5 (range 16-75) years at injury, appeared for follow-up. Seven patients had isolated injury of the lateral collateral ligament/capsular structures, the remaining 19 patients had concomitant ligament injuries in the knee. Eight patients were treated conservatively, 1 with plaster immobilization and 7 with early mobilization. Eighteen patients underwent surgery, 17 of these within 3 weeks of injury. Repair/reconstruction of the cruciate ligaments was done at the same time as the lateral collateral ligament repair in 10 patients. At follow-up after a median of 7.5 years (range 6 months to 13 years), 11 had no varus instability, 7 had 1+, 5 had 2+, and 2 patients had 3+ varus instability. All patients with a final result of 2+ or 3+ had combined ligament injuries. The surgically treated lateral collateral ligament injuries all had a primary instability of 2+ or more. These patients showed an improvement in varus instability from a mean of 2.83+ preoperatively to a mean of 1.17+ postoperatively. Two-thirds of the surgically treated patients were stable or had a 1+ instability at follow-up. One conservatively treated patient with a 2+ varus instability and 1 with 1+ showed no improvement. Five conservatively treated patients with initial varus instability of 1+ were stable at follow-up. One patient with a 1+ varus instability had anterior cruciate ligament (ACL) rupture. He had a primary ACL reconstruction without lateral repair. He had no varus instability at follow-up. Our study supports the notion that operation performed at an early stage in fresh injuries with a varus instability of 2+ or more gives improved stability as a final result. Conservative treatment may not be expected to give an improved stability, but is sufficient in mild varus instability (1+) without additional cruciate ligament injuries.

Mechanical effects of different localization of the point of entry in femoral nailing.

Twenty pairs of human femora were reamed alternatively on the right or left side, with the opposite side serving as the unreamed control. The fossa piriformis (group I) or tip of the greater trochanter (group II) were chosen for introduction of the intramedullary reamer (Howmedica type). The femora were tested in vertical compression in a MTS mechanical testing machine until failure. In group I, all femora fractured through the entry portal. This happened in only 3 out of 10 in group II, where 7 fractured through the medial part of the femoral neck remote from the portal. The difference is statistically significant. Reduction in strength between the unreamed control side and the reamed femur was median 1486 (23%) in group I and 506 N (11%) in group II. Reduction in energy absorption between the control side and reamed side was median 9786 Nm (44.5%) in group I and 1142 Nm (10.5%) in group II. The difference in energy absorption reduction between groups I and II was statistically significant (P = 0.04). We conclude that reaming through an entry point (portal) in the piriformis fossa weakens the femoral neck and creates a localizing point for fracture.

Closed reduction and external fixation of unstable fractures of the distal radius.

The anatomical and functional outcome and complications after closed reduction and external fixation of unstable fractures of the distal radius were reviewed in 29 patients. The fractures were reduced by longitudinal traction and closed manipulation under fluoroscopic control, and the reduced position was retained by a standard half-frame Hoffmann external fixator for six to eight weeks. The mean follow-up time was four (3-7) years. The reduction failed in three patients after too early removal of the fixator (three to five weeks). For the rest of the patients the dorsal angulation, the radial length, the articular step-off, and the intra-articular gap between fragments were significantly improved. Twenty-two patients had excellent or good anatomical alignment and in seven it was fair. One patient had a superficial pin infection, six patients had transient paraesthesias, and one patient transient mild dystrophia. At follow-up one patient had some finger stiffness; this was the only persistent complication. The median Gartland and Werley functional score was 3. The functional end result was excellent or good in 22 patients, fair in four, and poor in three.

Open reduction and internal fixation of displaced intraarticular fractures of the distal radius. 31 patients followed for 3-7 years.

We have used open reduction and internal fixation with a T-plate in 31 displaced, intraarticular fractures of the distal radius which were judged irreducible or in which closed reduction failed. The mean follow-up time was 4 (3-7) years. The dorsal angulation, the radial length, the articular step-off and the intraarticular gap between fragments were substantially improved after surgery. 30 patients had excellent or good extraarticular alignment, and only 1 patient had a postoperative intraarticular step-off of 2 mm. The function was excellent or good in 26 patients at follow-up. Complications occurred in 6 patients: 1 compartment syndrome, 1 postoperative wound infection, 2 ruptures of the extensor pollicis longus tendon, and 2 patients had median nerve paresthesias.

Open tibial fractures treated with the Ex-fi-re external fixation system.

Fifty open tibial fractures were treated with the Ex-fi-re external fixation system from 1987 to 1994. According to the Gustilo and Anderson classification, there were 12 Grade I, 14 Grade II, 10 Grade IIIA, 13 Grade IIIB, and 1 Grade IIIC injuries. Eight fractures were segmental. The average patient patient age was 39 years (range, 16-85 years). With the reduction unit of the system, displaced tibial fractures could be reduced by the functions of the device in contrast to the manual reductions needed with other unilateral devices. Compression could be applied even to oblique fractures. The reductions were performed by this unit in all cases and were classified as exact in 28 of 41 cases. Exact reduction was defined as a reduction in which there was no more than 2 mm of translational displacement. The 8 segmental fractures were not classified according to reduction. Forty-three fractures healed with no secondary procedure. Three secondary bone graftings, 4 fibulotomies, and 3 renamed intramedullary fixations were performed in 6 patients. Thirty-two skin grafts were performed. There was 1 fracture site infection, and 1 curettage and 1 sequestrectomy were performed after union. At 1 year followup there were no signs of infection. Median time to union was 20 weeks, and median time to full unprotected weightbearing was 22 weeks. Fractures with an exact reduction had a median time of union of 19 weeks, compared with a median of 31 weeks in reductions with greater than 2 mm translational displacement. The exact reduction and translational compression applied in oblique fractures appeared to contribute to early consolidation.

11 femoral fractures with vascular injury: good outcome with early vascular repair and internal fixation.

We reviewed 11 consecutive cases with combined femoral fracture and vascular injury presenting with acute ischemia. 6 cases had ischemia exceeding 8 hours and 4 of them developed massive muscle necrosis in the lower leg. 5 cases with ischemia less than 8 hours had no muscle necrosis. Vascular repair preceded fracture stabilization in 5 cases; there were no vascular complications during the subsequent fracture stabilization. 6 fractures treated with internal fixation had uneventful fracture-healing, whereas the 4 which were treated with external fixation needed later reoperations to obtain fracture-healing. We conclude that the limb must be reperfused within 6-8 hours. Vascular repair should be the first procedure, and fracture fixation by internal fixation is then preferred.

A prospective, randomized study of three operations for acute rupture of the anterior cruciate ligament. Five-year follow-up of one hundred and thirty-one patients.

A five-year, prospective, randomized follow-up study was done to compare three methods for repair of a rupture of the anterior cruciate ligament of the knee; acute primary repair (Group 1), acute repair with a synthetic ligament-augmentation device (Group 2), and acute repair augmented with an autologous bone-patellar ligament-bone graft (Group 3). One hundred and fifty patients who had an acute rupture of the anterior cruciate ligament were randomized to one of the three repair groups, with fifty patients in each group. The patients were between sixteen and fifty years old (mean, twenty-nine years old). All patients had the operation within ten days after the injury. The rehabilitation protocol was identical for each group. The patients were evaluated prospectively at one, two, and five years with use of the Tegner scoring system for level of activity and the scoring system of Lysholm and Gillquist for function, and the stability of the knee was assessed with clinical examination and with use of the KT-1000 arthrometer. One hundred and thirty-one patients completed the study and ten other patients were known to have had a failure of the procedure, a 94 percent rate of follow-up. All three groups had a lower level of activity at the five-year follow-up evaluation than they had had before the injury. The patients who had had augmentation with a patellar-ligament graft had a significantly higher mean level of activity at two years than those who had had non-augmented repair with (p = 0.002) and those who had had repair with a synthetic ligament-augmentation device (p = 0.01). They also had a significantly higher mean level of function at two years than those who had had non-augmented repair (p = 0.0001) and those who had had repair with a synthetic ligament-augmentation device (p = 0.03) and a significant higher mean level of function at five years than those who had had non-augmented repair (p = 0.004). The ability to attain full extension improved significantly in all three groups during the five-year follow-up period; the highest gains occurred in the group that had had augmentation with a patellar-ligament graft. Rotatory and anterior instability progressively increased during the follow-up period for all three groups. At one, two, and five years, the knees that had had repair with a patellar-ligament graft were significantly more stable than those that had had non-augmented repair and those that had had repair with a ligament-augmentation device (p < 0.0001 to p = 0.03). The findings of this study reinforce the conclusions of our two-year follow-up report that a non-augmented primary repair should not be performed, a repair with a ligament-augmentation device has an unacceptably high rate of failure (more than one-third of the patients), and a repair that is augmented with the patellar ligament has the best outcome.

Meniscal lesions treated with suture: a follow-up study using survival analysis.

Fifty-seven patients, 45 males and 12 females with a median age of 23 years (range 8-56), underwent meniscal refixation by suture from 1986 through 1991. We used an arthroscopic outside-in technique with PDS sutures through injection cannulas. Thirty-six knees were stable and 21 had anterior cruciate insufficiency, five of which were subjected to surgery concomitantly with patellar tendon reconstruction and two of which were subjected to surgery at a later occasion. Fifty-one patients could be evaluated at a follow-up time of 2 months to 5.5 years (median 1.5, mean 2), and calculations were made using the BMDP statistical package and the Kaplan-Meier survival analysis. No serious complications were encountered. Twenty patients (39%) have undergone reoperation because of meniscal rerupturing. At 5 years, the cumulative survival rate is 50%. Smaller (posterior) lesions healed better than did more extensive lesions. No statistical influence of factors such as medial or lateral localization, age of patient or lesion, present displacement of meniscus, instability of the knee, or experience of the surgeon was evident.

Surgery for posttraumatic wrist deformity. Radial osteotomy and/or ulnar shortening in 16 Colles' fractures.

16 patients with pain and impaired function after malunited fracture of the distal radius were treated with opening wedge lengthening osteotomy of the radius with bone grafting (12 cases), shortening osteotomy of the ulna (3 cases), or a combination of these methods (1 case), with or without reattachment of the triangular fibrocartilage complex. 4 patients had to be reoperated because of redislocation, resorption of the graft, fracture of the plate, or persistent non-union. At re-examination after a median of 4 years, all patients but 2 were improved by the procedure.

[Follow-up of sutured meniscus by means of survival analysis]. / Etterkontroll av suturert menisk ved bruk av overlevingsanalyse.

We describe a retrospective study of patients operated by meniscal suture at our hospital from 1986 through 1992. 63 patients were operated, 50 males and 13 females. Mean age was 26 years. Complete data were retrieved at follow-up for 57 patients. Mean observation time was two years. 90% were operated using the arthroscopical technique. 25 patients have been re-operated because of meniscal rerupture. The cumulative survival rate was 44% five years after operation. Survival analysis revealed no significant differences by variables such as sex, age, instability and lateral or medial location revealed. Experienced surgeons achieved only insignificantly better long-term results than did trainees. There was no significant difference in healing rate between displaced bucket-handle and non-displaced tears, nor between chronic and acute tears.

[Surgical treatment of fractures of the acetabulum]. / Operativ behandling av acetabularfrakturer.

Since January 1988, 18 patients with acetabular fractures were operated on. Seven fractures were "both columns", six were posterior wall fractures, four were of the transverse/single column types, and one was unclassified. Four patients were operated by ileo-inguinal incision alone, three by combined ileo-inguinal and posterior Kocher-Langenbeck, ten by Kocher-Langenbeck, and one by triradiate incision. Early complications were 1 DVT and 1 infection (subsided after removal of the plate from crista iliaca). One patient with brain injury developed cerebral infarction, and one multi-traumatized patient died of lung embolus after transfer to another hospital. 11 patients are back at work, one has retired, and two are seeking new education after the injury. We conclude that operative treatment is indicated for these fractures, and that the results and rate of complications are acceptable. This treatment should be centralized.

[Primary suture of the posterior cruciate ligament]. / Primaer sutur av bakre korsband.

23 acute midsubstance ruptures of the posterior cruciate ligament were treated by primary suture. 20 patients returned for follow-up. Four of them had an isolated rupture of the PCL. The remaining 16 patients had sustained combined injuries to ligaments, including eight total ruptures of the anterior cruciate ligament. All ruptured ligaments were sutured. At follow-up (median = 5.5, range 3-10 years) median knee score according to Lysholm was 81 (range 53-100). Five were rated excellent, six good, three fair and six poor. KT-1000 arthrometer measurements revealed a posterior instability of between 5 and 10 mm in five patients and below 5 mm in 14 patients. Thus, in most patients, some instability remained in spite of operative treatment.

[Arthroscopy of the elbow]. / Albueartroskopi.

We present experience from 37 arthroscopies of the elbow. 15 surgical procedures were performed, nine of which were extractions of free bodies. One deep infection occurred (in the first patient, on whom arthrotomy was performed as well), but no neurovascular complications occurred. Three preoperative diagnoses were changed, and a diagnosis could be made in 14 cases of unknown etiology. Exploratory arthrotomy was avoided in 13 patients. In our view the method is indicated in cases of pain of unknown cause, free intraarticular bodies and/or osteochondritis, and locking episodes where no reason could be established preoperatively. Morbidity is minimal and visualization is better than in open surgery.