The Olerud Cervical Fixation System; a study of safety and efficacy.

To evaluate safety and efficacy of the Olerud Cervical Fixation System a one-year follow up study was done by an independent observer. There were 30 patients (14 women) with a mean age of 68 (37-85) years. Indications were rheumatoid arthritis in 10, spinal stenosis in 6, trauma in 6, metastases in 4, revisions in 3, and painful spondylotic deformity in one patient. Short fusions were performed in 8 patients and long fusions in 22. Four patients were fused to occiput. C1-C2 fusion was performed in 3 patients. Nineteen of the 20 still alive were evaluated at follow up. One patient was deliberately fused in hyperlordosis, in the rest the alignment was acceptable. Primary stabilization was achieved in all but one. 107 pedicle screws were used; one screw in Th2 was placed lateral to the pedicle. 42 subaxial transarticular screws were used. There were no complications related to these screws. One patient experienced a non-instrument related neurological deterioration. Two infections and one hematoma drainage healed on conservative treatment. Loss of fixation and non-union developed in 2 patients. Patients with metastasis or myelopathy due to rheumatoid arthritis carried a high mortality risk. The Olerud Cervical Spine Fixation System is versatile in posterior fixation of the cervical spine and has proven to be both safe and efficient.

The Wagner revision stem for severe osteolysis. 31 hips followed for 1.5-5 years.

We used the Wagner (1989) method in 31 hip revisions because of loosening with pronounced scalloping, which made a conventional revision unsuitable. The radiographs showed that within a few months new bone developed in the defects. In 5 cases, a new revision was necessary at an early stage, because of dislocation and/or subsidence. At follow-up after 3 (1.5-5) years, 21 of the remaining 26 hips were pain-free and 23 had almost full range of motion.

Mobility in the cervico-thoracic motion segment: an indicative factor of musculo-skeletal neck-shoulder pain.

The aim of the study was first to evaluate whether mobility in the cervico-thoracic motion segment is an indicative factor of musculo-skeletal neck-shoulder pain and secondly to compare differences in individual factors between cases and controls for female and male subjects. One-hundred-and-forty-two male electricians and 139 female laundry workers participated in a cross-sectional study. An examination of the Cervico-Thoracic Ratio and a classification of mobility at level C7-T1 was done. All subjects answered a questionnaire about musculo-skeletal complaints. The analysis of relationship between relative flexion mobility in motion segments C7-T5 and neck-shoulder pain showed significant relationships between mobility in specific motion segments and neck-shoulder pain. The overall fit of the multiple regression analysis explained 10% of the variation in neck index (N1) for subjects classified as hypomobile at level C7-T1 and 18% for subjects classified as having an inverse C7-T1 function. Both female and male subjects classified as hypomobile at level C7-T1 showed elevated odds ratios of 2.7 and 2.2, respectively, to have had more than 7 days of neck pain during the previous 12 months, compared to subjects classified as having ordinary mobility at level C7-T1. The factor age showed that young subjects with hypoar hypermobility at level C7-T1 showed elevated odds ratios for neck pain compared to subjects with ordinary mobility in the same age group. In old subjects hypermobility at level C7-T1 was protective compared to subjects with ordinary mobility in the same age group. The factor number of working years showed significant difference between cases and controls among female subjects in the ordinary and hypermobile classes. The factor height showed no significant differences between female or male cases and controls; it did show significant correlation to C7-T1 mobility among female subjects, but not among male subjects. The factors exercise and smoking showed significant differences between cases and controls among female subjects in the ordinary mobility class. The conclusion was that relative flexion mobility is a factor related to the development of neck-shoulder pain rather than the cause of pain.

Conventional radiography and bone scintigraphy in the prognostic evaluation of Legg-Calvé-Perthes disease.

PURPOSE: The role of conventional radiography and bone scintigraphy in predicting the outcome of Legg-Calvé-Perthes disease was investigated. MATERIAL AND METHODS: The 75 children reviewed (86 hips) were followed up to the primary healing of the disease. The findings at conventional radiography (obtained at presentation, at the time of maximum capital head involvement, and at the end of the healing process of the disease) were compared to early bone scintigraphy features. RESULTS AND CONCLUSIONS: Bone scintigraphy provided more accurate information concerning the extent of the necrotic process than initial radiographs. Moreover it could determine revascularization and consequently the stage of the disease. The methods was, however, unable to predict the outcome of the disease in some cases, particularly if it was performed late after the onset of symptoms. Conventional radiography provided important information about other parameters such as "head-at-risk" signs which facilitated treatment selection. Of these signs not only lateral subluxation but also metaphyseal changes strongly predispose to severe deformity of the hip joint.

Marmor modular knee plateau positioning and prosthesis survival in 55 knees with rheumatoid arthritis.

In a long-term follow-up of 55 Marmor knee arthroplasties in patients with rheumatoid arthritis operated on between 1975 and 1977, the radiologically visible indicator wire was used to identify the position of the tibial components. The survival rate of the prostheses at 15 years was 0.71, and the revisions were evenly distributed over the observation period of 16 years. No significant relationship was found between the slope of the tibial components postoperatively and the survival of the prostheses. However, a postoperative valgus angle of the leg of 3 deg or more tended to increase the risk of revision (RH = 2.7, 95% CL = 0.8-8.9). The patient's sex, affected side or weight did not influence prosthesis survival.

Legg-Calvé-Perthes disease. Comparison of conventional radiography, MR imaging, bone scintigraphy and arthrography.

In a prospective study of 22 patients (24 hips) with Legg-Calvé-Perthes disease (LCPD) the findings at conventional radiography, arthrography, bone scintigraphy and MR imaging, obtained at the time of diagnosis, were compared. MR was superior to conventional radiography and bone scintigraphy in the detection of the extent of involvement in the femoral head. Arthrography was as good as or better than MR imaging in determining the shape of the articular surfaces and the occurrence of lateral subluxation. Conventional radiography was less sensitive in identifying the degree of lateral subluxation and the extent of the necrosis in the femoral head. MR imaging provided anatomical and pathophysiological information about the extent and location of head involvement as well as the degree of lateral subluxation. Revascularisation was more clearly demonstrated with MR than with bone scintigraphy, irrespective of symptom duration.

A clinical method for measuring segmental flexion mobility in the cervico-thoracic spine and a model for classification.

Pain and limitation of spinal mobility are symptoms frequently reported by patients. Many methods have been used to assess the total range of mobility in the different parts of the spine, but there is no method for clinical examination of segmental mobility. The aim of this study was to describe such a technique concerning of segmental flexion mobility in the cervico-thoracic spine, C7-T5, and to present a model for classification of mobility. The results of this study show that the relative flexion mobility examined, according to the Cervico-Thoracic-Ratio technique (CTR), may become a valuable complement to conventional methods of assessing mobility in the cervical spine. The normalized CTR values are less influenced by the individual factors age, body weight, height and number of years at work and the classification model presented makes functional analysis of segmental flexion mobility in the cervico-junction and upper thoracic spine more substantial.

A clinical method for measuring the distribution of segmental flexion mobility in the cervico-thoracic spine.

The aim of this study was to evaluate the validity and the repeatability of a new technique to assess segmental flexion mobility in the cervico-thoracic spine between segments C7 and T5. The new technique is referred to as the Cervico-Thoracic-Ratio (the CTR-technique). The radiological evaluation of skin distraction measurements showed that validity was high for the CTR-technique. A high correlation between vertebral flexion mobility and skin distraction was recognized individually and for the whole group. The evaluation of repeatability was found to be high for intratester and fair for intertester repeatability. The CTR-technique may become a valuable complement to other methods for assessing segmental flexion mobility in patients suffering from neck-shoulder pain in clinical practice.

Findings and outcome in whiplash-type neck distortions.

STUDY DESIGN: The authors assessed the clinical and imaging findings and late outcome in 50 patients with whiplash-type neck distortions (17 men, 33 women, mean age 33 years). SUMMARY OF BACKGROUND DATA: Early symptoms are neck pain, stiffness, and sometimes radiating pain; later bizarre symptomatology poses intricate clinical and medicolegal problems. Pathoanatomic studies indicate that soft tissue injuries may be overlooked. METHODS: Repeated clinical and radiographic examinations (plain and flexion-extension radiograms and contrast magnetic resonance imaging evaluated with a new grading system); surgical findings; follow-up were performed after 1 and 5 years by an independent observer neurologist. RESULTS: Neck pain persisted in 24 patients; radiating pain developed within 6 weeks in 19 patients. Two patients with segmental instability had posterior fusions and complete pain relief. Eight patients with severe radiating pain and large disc protrusions on magnetic resonance had nine surgically confirmed fresh disc herniations. Discectomy and fusion alleviated pain in these patients, whereas symptoms largely persisted in the conservatively treated patients. CONCLUSIONS: A high incidence of discoligamentous injuries was found in whiplash-type distortions. Most patients with severe persisting radiating pain had large disc protrusions on MRI that were confirmed as herniations at surgery. Neck and radiating pain were alleviated by early disc excision and fusion.

Stretchability of the rectus femoris muscle: investigation of validity and intratester reliability of two methods including X-ray analysis of pelvic tilt.

Validity and intratester reliability of two test methods designed to identify stretchability of the rectus femoris muscle (RFM) was investigated, combined with x-ray analysis of pelvic tilt in the sagittal plane. The first method is commonly used in clinical practice. The second is a new technique supposed to tilt the pelvis posteriorly and thus further separate the origin and insertion of the muscle. Investigation of validity and intratester reliability of the two methods was made by testing and retesting a random sample of 71 persons. The tests were performed with an equipment that automatically recorded the angle of knee flexion from a previously determined applied torque, indicating the end point of motion for that particular subject. Angle of knee flexion and subjective estimation of pain sensation due to stretch were recorded at each measurement. The pelvic tilt-analysis consisted of test-retest reliability of x-ray measurements, comparison between the methods in both starting and final position, and x-ray and electronic goniometer measurements. All applied torques were measured with a strain gauge. Two out of three criteria of validity favored the new method and the third pointed out the two methods as equal. The two methods as well as the x-ray measurements showed high reliability, and the hypothesis of a more posterior tilted pelvis in the new method was confirmed. The electronic goniometer was less sensitive than x-ray, but proposed to analyse pelvic tilt clinically. Methodology procedures for joint angle measurements are discussed.

Hidden cervical spine injuries in traffic accident victims with skull fractures.

We studied 22 cervical spines from traffic accident victims with fatal craniocerebral injuries (19 male victims and three female victims; mean age, 26 years). Two had parietal fractures, 20 had skull base fractures (seven ring fractures), and 16 had severe polytrauma. The spines with all soft tissues were frozen in situ and removed. Fine-focus specimen radiograms were taken in special views and evaluated by an expert orthopedic radiologist. The specimens were then cryosectioned, and all injuries were recorded at submillimeter intervals on high resolution film. Ten radiological fracture diagnoses were incorrect; six were false positive, and four were false negative. In the upper cervical spine, only one of 10 gross ligamentous disruptions was suspected on the radiograms. In the lower cervical spine, 198 lesions were missed on the radiograms: 77 facet joint and ligamentum flavum injuries, 77 uncovertebral, and 22 disc lesions. In two adolescents, eight cartilaginous end-plate avulsions of the discs were found. At second-look evaluation, only four of the 245 unrecognized bone and discoligamentous lesions were detected on the radiograms. All spines were injured. Multiple-level soft-tissue injuries were common.

Influence of pelvic position on radiographic measurements of the prosthetic acetabular component. An experimental study on a pelvic model.

A change in the position of a prosthetic acetabular component between two different radiographic examinations indicates loosening, and may be observed as tilting or migration of the socket. To determine the apparent changes in socket position caused by improper positioning of the pelvis, a full-scale model of a pelvis with attached prosthetic sockets was examined radiographically in different positions. The projected alignment of the Charnley socket indicator wire against the inter-tuberosity line was markedly influenced by the positioning of the pelvis. An alternative way of measuring the alignment is to use the long axis of the projected ellipse of the outer circumferential groove in the socket polyethylene. The thus defined socket alignment was not influenced by the positioning of the pelvis within the investigated range. No apparent socket migration was recorded within the range of pelvic rotation and inclination studied.

Role of talocalcaneal osteotomy in clubfoot surgery: results in 31 surgically treated feet.

The most important deformities in clubfeet can be demonstrated by simultaneous arthrography of the talonavicular and talocrural joints. In patients with a severe talar deformity, wedge osteotomy through the talar neck and calcaneus has been performed as a prerequisite for correction. Our series consisted of 20 patients with 31 idiopathic clubfeet with pronounced talar deformity. The mean observation time after osteotomy was 11 years 3 months. The principles and aims are described, as are the indications for talocalcaneal osteotomy. Results were good in 19 feet (60%), fair in six (20%), and poor in six (20%).

Subchondral screw fixation of cervical hip fractures: joint congruence studied with combined arthrography and tomography.

This study was done to determine whether fixation with the Uppsala internal fixation technique into the subchondral bone of the femoral head in the treatment of cervical hip fractures could lead to elevation of the femoral head cartilage. Combined arthrography and frontal tomography of the hip joint in the plane of the screws was performed. The series consisted of 16 patients. In two of the patients, the tips of the screws had penetrated into the cartilage of the femoral head. In the other 14, the internal fixation was technically correct with the tips of the screws in the subchondral bone. In the two hips with the screws penetrating into the cartilage, the cartilage was slightly elevated. In the hips where the screws were in the correct position, no incongruities or deformity in the cartilage could be detected. Combined arthrography and frontal tomography can, therefore, detect elevation of the cartilage of the femoral head. By placing the screws in the immediate subchondral bone, no elevation of the cartilage of the femoral head surface should occur.

Measurement of the motion range in the loaded ankle.

In an easily practicable method of measuring the motion range in the ankle under load, the patient is asked to put his foot on a 30-cm-high stool and then lean forward as much as possible without lifting his heel from the supporting stool. In this position the knee is flexed and the greater part of the body weight is on the examined foot. Dorsal extension is then measured with a protractor as the angle between the support line of the foot and the long axis of the leg. The loaded plantar flexion is measured in the same position but with the heel raised as much as possible. In a study of 317 healthy ankles, this method was found to give greater and more reproducible values than measuring on unloaded ankles in sitting or supine positions. Measurements of the loaded dorsal extension were also made on radiographs of 66 healthy ankles. The mean value was 32.5 degrees; the mean talar forward tilt was 5.0 degrees. In normal daily life, at least 10 degrees are required; for performing athletics and sports activities, a loaded dorsal extension range of 20 degrees-30 degrees is necessary.

Thromboembolism after total hip replacement: role of epidural and general anesthesia.

The effects of continuous epidural anesthesia and of general anesthesia on the incidence of thromboembolism following total hip replacement were studied. Sixty patients were randomly allotted to one of two groups receiving either epidural or general anesthesia. Epidural anesthesia (N = 30) consisted of 0.5% bupivacaine with epinephrine intraoperatively; for pain relief in the postoperative period (24 h), 0.25% bupivacaine with epinephrine was given every 3 h. General anesthesia (N = 30) consisted of controlled ventilation with N2O-O2 and intravenous fentanyl and pancuronium bromide; postoperatively, narcotic analgesics were given intramuscularly on demand for pain relief. Significantly lower frequencies were found following epidural anesthesia than after general anesthesia in deep venous thrombosis involving the popliteal and femoral veins (13% and 67%, respectively), deep venous thrombosis involving both calf and thigh veins (40% and 77%), and pulmonary embolism (10% and 33%). Possible explanations for these differences include increased circulation in the lower extremities, less tendency for intravascular clotting to occur, and more efficient fibrinolysis in association with continuous epidural anesthesia. The decrease in blood loss associated with epidural anesthesia with lower transfusion requirements also might play a role. Epidural analgesia prolonged into the postoperative period, in addition to other appropriate thromboprophylactic measures, should be of value in patients undergoing operations associated with a high risk of thromboembolic complications.

Comparative influences of epidural and general anaesthesia on deep venous thrombosis and pulmonary embolism after total hip replacement.

In an investigation on deep venous thrombosis and pulmonary embolism, where neither dextran nor antithrombotic drug prophylaxis were employed, 30 patients undergoing total hip replacement were randomly allotted to one of two groups receiving either epidural or general anaesthesia. The epidural group (n = 15) was given 0.5% bupivacaine with epinephrine (5 micrograms/ml) and this was prolonged into the postoperative period for pain relief. The general anaesthesia group (n = 15) was operated on under artificial ventilation with nitrous oxide/oxygen via an endotracheal tube and intravenously administered fentanyl and pancuronium bromide. In this group of patients narcotic analgesics (ketobemidone) were given intramuscularly on demand for pain relief postoperatively. The frequency of deep venous thrombosis involving the femoral veins, as observed at phlebography, was significantly lower in patients receiving continuous epidural block (3 of 15; 20%), than in those receiving general anaesthesia and parenteral analgesics postoperatively (11 of 15; 73%). Further, the frequency of pulmonary embolism, as determined by pulmonary perfusion lung scanning, was lower in patients receiving continuous epidural block (2 of 15) than in the general anaesthesia group (7 of 15). Possible explanations for these findings are discussed, including a hyperkinetic lower limb blood flow and lower fibrinolysis inhibition activity in patients given epidural block. Lower blood transfusion requirements in patients given epidural block might also play a role, as well as a "stabilizing" effect of local anaesthetics on platelets, leukocytes and endothelial cells.

Effects of tocainide, an oral analogue of lidocaine, on thromboembolism after total hip replacement.

In an investigation of deep venous thrombosis and pulmonary embolism, where neither dextran nor other antithrombotic drug prophylaxis was employed, 30 patients subjected to total hip replacement under general anaesthesia were randomly allotted to one of two groups. One group (n=15) received tocainide, an oral analogue of lidocaine, as a means of preventing thromboembolism; the other group (n=15) served as a control. In patients given tocainide the frequency of deep venous thrombosis involving the femoral veins, as observed at phlebography, was 60% (9 of 15), and in the control group 73% (11 of 15). The frequency of pulmonary embolism, as determined by pulmonary perfusion lung scanning, was 20% (3 of 15) in the the tocainide group and 33% (5 of 15) in the control group. It was concluded that tocainide administration had no effect as an antithromboembolic agent. Phlebography revealed that the pattern of deep venous thrombosis after total hip replacement was characterized by a high frequency of isolated thigh vein thrombi in the operated leg, probably related to the surgical procedure. A finding of possible clinical significance was that patients given tocainide had a significantly lower intraoperative blood loss than control patients.