Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems.

We compared the efficacy of the Medoff sliding plate (MSP) with 3 other screw-plate systems for fixation of unstable intertrochanteric fractures in a randomized multicenter trial of 569 elderly patients. The MSP has biaxial dynamic capacity along both the neck and the shaft of the femur unlike the other systems, which lack dynamic capacity along the shaft. 268 fractures were operated on with the MSP, and 301 with the dynamic hip screw (DHS), with or without a trochanteric stabilizing plate (DHS/TSP) or with the dynamic condylar screw (DCS). The MSP had recently been shown to the surgeons. The patients in the groups were similar as regards age, domestic situation, preinjury walking ability and type of fracture. We followed the patients clinically and radiographically for at least 1 year. There was no significant difference in walking ability at follow-up or rate of return to home. Fixation failure occurred in 18/268 fractures operated on with the MSP, in 8/238 with the DHS, in 3/49 with the DHS/TSP and in 1/14 with the DCS. The difference in the rate of fixation failure was not statistically significant when the MSP group was compared to the 3 other groups. In 14 of the 18 fixation failures in the MSP group, the biaxial dynamic capacity of the MSP had not been used due to technical errors by surgeons, unfamiliar with the new method. No selection bias was found regarding fracture types in the 2 subgroups of patients with correct or inadequate biaxial dynamization. Extramedullary fixation of unstable intertrochanteric fractures with these implants showed a low failure rate. When using the MSP, biaxial dynamization must be correctly performed.

Extramedullary fixation of 107 subtrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus 3 other screw-plate systems.

We compared the efficacy of a load-sharing device, the Medoff sliding plate (MSP), with that of 3 other load-bearing screw-plate devices for the fixation of subtrochanteric fractures in a randomized multicenter trial of 107 elderly patients. 55 fractures were operated on with the MSP, and 52 with the dynamic hip screw (DHS) with or without a trochanteric stabilizing plate (TSP) or with the dynamic condylar screw (DCS). The patient material in the groups was similar regarding age, domestic situation, preinjury walking ability and fracture types. We followed the patients clinically and radiographically for a minimum of 1 year. There was no significant difference in walking ability or return rate to the home at follow-up. Fixation failure occurred in 1/55 fractures operated on with the MSP, in 3/32 with the DHS, in 3/12 with the DCS and in 2/8 with the DHS/TSR The difference in the rate of fixation failure was statistically significant, when the MSP group was compared to the 3 load-bearing devices in the other group (1 vs 8). On the basis of this experience, we think that the load-sharing principle of the MSP, which seems to facilitate fracture impaction and stability, appears to be a good alternative in extramedullary fixation of subtrochanteric fractures.

Different ways to treat subtrochanteric fractures with the Medoff sliding plate.

Thirty-two consecutive subtrochanteric fractures in 32 patients were stabilized using the Medoff sliding plate and were followed up prospectively for 1 year. Two patients died during the first postoperative year. Twenty-nine of the remaining 30 (97%) fractures united by 1-year followup. Two types of plate dynamization schema were used: uniaxial (17 patients) and biaxial (15 patients). With uniaxial dynamization, plate sliding averaged 12 mm along the femoral shaft without medialization of the femoral shaft. With biaxial dynamization along the femoral shaft and the neck, plate sliding averaged 11 mm and screw in barrel sliding averaged 9 mm; medialization of the femoral shaft ranged from 0% to 35% of the femoral shaft diameter. Three fractures treated with uniaxial dynamization had migration of the lag screw within the femoral head; all three fractures united without additional screw migration after secondary or staged biaxial plate dynamization.

A new radiographic method for evaluating the degree of sliding in devices used in hip-fracture surgery.

PURPOSE: To find a practical method for estimating the degree of sliding that occurs in screw-plate devices used in hip-fracture surgery. Greater understanding of the sliding mechanisms in different fracture types should improve surgical technique and reduce the failure rate. METHODS AND RESULTS: In dynamic screw-plate devices, the lag screw slides inside the barrel of the plate. A recent innovation allows the barrel-plate to slide inside a side-plate, thus making possible a combined fracture compression along the neck and the shaft of femur. The lengths of the different parts and the angle of a device in vivo, measured on a radiograph, depend on the position of the femur relative to the photographic film and the roentgen source. We obtained these measurements with a ruler and a protractor from sequential a.p. radiographs of the hip and implemented them in a special computerized program that used the principles of the scaled orthographic and the central projection models. These calculations provided the correct amount of sliding by the lag screw and by the barrel-plate within the side-plate. CONCLUSION: The method presented here can establish the real degree of sliding in screw-plate devices from standard a.p. radiographs independently of the position of the hip.

Two-way compression along the shaft and the neck of the femur with the Medoff sliding plate: one-year follow-up of 108 intertrochanteric fractures.

The Medoff sliding plate (MSP) is a new device used to treat intertrochanteric and subtrochanteric fractures. There are three options for sliding; either along the shaft or the neck of the femur, or a combination of both. In a prospective series of 108 consecutive displaced intertrochanteric fractures we used combined dynamic compression. The patients were followed clinically and radiologically for one year. All fractures healed during the follow-up period. The only postoperative technical failure was one lag-screw penetration. Combined compression of the MSP gives increased dynamic capacity which reduces the risk of complications. The low rate of technical failure in our series compares favourably with that of the sliding hip screw or the Gamma nail but randomised trials comparing the MSP with other hip screw systems are necessary to find the true role of the MSP with its various sliding modes.

One-way compression along the femoral shaft with the Medoff sliding plate. The first European experience of 104 intertrochanteric fractures with a 1-year follow-up.

This is an assessment of a new device for treatment of intertrochanteric and subtrochanteric fractures. The Medoff sliding plate (MSP) allows compression in 3 different modes: along the femoral shaft, along the femoral neck or a combination of both. In this prospective series of 104 consecutive intertrochanteric fractures, dynamic compression was allowed only along the femoral shaft. Simple undislocated intertrochanteric 2-part fractures were excluded. The patients were followed clinically and radiographically for 1 year. 21 patients died within 1 year after the operation. 7 technical failures including 2 non-unions occurred. All were lag screw penetrations, 4 of which were considered to be due to unforced errors by the surgeons. The technical failure rate in this preliminary evaluation of the MSP is similar to that of the dynamic hip screw. Randomized trials comparing the MSP with other hip screw systems should follow to ascertain possible advantages of the MSP, with its various sliding modes in different types of fractures of the proximal femur.

Disease activity and joint damage progression in early rheumatoid arthritis: relation to IgG, IgA, and IgM rheumatoid factor.

The clinical and biochemical correlations with joint damage progression over two years in a consecutive group of 68 patients with rheumatoid arthritis with disease duration of less than two years are reported. Joint damage was assessed with Larsen's severity scale and a measure of change in progression rate constructed. Initial haemoglobin concentration, Ritchie index, and Waaler-Rose titre in combination accounted for one third of the variance in joint damage progression. Rheumatoid factor (RF) concentrations were followed with enzyme linked immunosorbent assays (ELISAs) for IgG RF, IgA RF, and IgM RF. The RF concentrations, except IgG RF, decreased with time; significant correlations between RFs and disease activity were few and barely clinically useful. After two years IgG RF correlated significantly with a radiological score if early non-erosive changes were omitted. All RFs tended to correlate better with this radiological score at all three observation points. Analyses of the change in progression rate indicated a time delay between development of radiographic changes and increase of IgG RF. These results suggest an indirect relation between RFs and joint damage. Clinical and biochemical improvements in early RA occur despite joint damage progression, and conventional markers have insufficient predictive value.

Tourniquet infusion chemotherapy of the lower extremities--clinical and pharmacokinetic results.

A prospective analysis of tourniquet infusion chemotherapy is reported. Twelve patients with recurrent malignant melanoma and one patient with Kaposi's sarcoma on the lower extremities were treated. An objective tumor response (CR + PR) was noted in 4/8 patients with DTIC and in 1/5 with Adriamycin. Stable disease was registered in 2/8 and 2/5 when respective drugs were used. No major side effects were observed. Pharmacolkinetical analysis of Adriamycin were performed in five patients after two to three treatments. The plasma concentration time-curves of Adriamycin were in most cases described by an open three-compartment model. The AUC (area under the curve) values for Adriamycin were 3.4 (median value 95% CI 2.9-5.1) times higher than for Adriamycinol. The reproducibility of the intra-arterial techniques was established by the repeated pharmacokinetic analysis. This technique seems to give lower AUC (mg/m2) when compared with earlier published intravenous data. The results indicate that tourniquet infusion chemotherapy produces a reasonable response, and that further evaluation with other drugs and comparison with isolation hyperthermic drug perfusion will be of interest.

Management of inflammatory abdominal aortic aneurysm.

Some of the pitfalls in the management of inflammatory abdominal aortic aneurysm are stressed in the presentation of six illustrative cases. Background data on the presumed etiology and common symptoms are provided. The diagnostic value of computed tomography for preoperative detection of the fibrosis surrounding these aneurysms and the differentiation from other conditions are also discussed.

Prediction of sepsis neonatorum following a full-term pregnancy.

The aim of the present study was to identify obstetrical factors predicting sepsis neonatorum following a full-term pregnancy. In 1982 26 infants out of 2,977 full-term pregnancies had septicemia. For comparison 42 women of corresponding age were randomly selected. A stepwise regression analysis was performed in order to evaluate the association between seven different variables and sepsis neonatorum. We found that prolonged rupture of the membranes (p less than 0.003) and primary amniotomy (p less than 0.02) were the most important factors predicting sepsis neonatorum (r2 = 0.22). Factors such as cervical ripening, vaginal examinations, intrauterine monitoring devices, prolonged labor and prolonged pregnancy did not add to the predicted power of the analysis.

Wagner surface replacement of the hip. Three to six year follow-up.

Forty-two Wagner surface replacements were followed prospectively for 4 (3-6) years. Fifteen hips required rearthroplasty, in 11 cases owing to loosening and in 2 cases because of fracture of the femoral neck.

Trichorhinophalangeal syndrome type I: symptoms and signs, radiology and genetics.

The present study shows the occurrence of the trichorhinophalangeal syndrome type I in a Swedish family. Five members were affected and they were examined clinically and radiologically, and four of them were also cytogenetically examined. Three of them had dysplasia of the hip joints reminiscent of the Legg-Calvé-Perthes disease. Functional hand problems were common. High resolution G banding displayed normal chromosome complements. The inheritance was autosomal dominant. The data presented stress the importance of identifying the syndrome early in life so as to prevent the development of impaired hand and hip function.

Angiography as diagnostic, prognostic and therapeutic tool in liver metastases from a colo-rectal primary tumor.

Angiograms from 60 patients with liver metastases from colo-rectal carcinoma were reviewed in retrospect to find prognostic parameters. All patients were treated with intraarterial cytostatic drugs. Patients with a small tumor mass in the liver survived significantly longer than those with a huge tumor burden. A longer survival was seen also in patients who developed occlusion of the hepatic arterial tree. When the tumor showed reduction in size or was stationary at the follow-up angiographic examinations after institution of therapy survival was markedly improved. When compared with the findings at laparotomy, angiography adequately demonstrated tumor growth in the right lobe of the liver but repeatedly failed to do so in the left lobe. In 14 patients computed tomography was also performed. Tumor localization by CT corresponded well with the findings at laparotomy and was thus more accurate than the results by angiography. Information about tumor volume and number of tumor nodules was approximately the same with the two methods.

Ectopic bone after hip replacement. Excision and free fat transplants in four cases.

In four patients ectopic bone formed after total hip replacement was replaced with free fat transplants. One year later the patients were free from pain, and hip flexion had increased by 60 degrees on average. Ectopic bone was completely absent in one patient, and markedly reduced in the remaining three patients. Bone scintigraphy was found to be a sensitive technique to reveal early ectopic bone formation. Fat transplantation seems to be a satisfactory complement in the treatment of ectopic bone.

Subcapital fractures of the fifth metacarpal bone.

The incidence of upper extremity fractures was 8.8 per 1,000 inhabitants per year. Five per cent of these fractures occurred in the subcapital region of the fifth metacarpal bone. In a patient series the volar angulation after subcapital fracture of the fifth metacarpal bone was determined with a novel technique and related to functional and cosmetic outcome. In spite of volar angulation, the patients' discomfort was minor. An absolute volar angulation exceeding 30 degrees requires reduction, however.

55 degrees posterior oblique tomography of the pulmonary hilum in the evaluation of lung tumors.

Findings at 55 degrees posterior oblique tomography and chest films were compared to those at thoracotomy in 53 patients with malignant lung tumor. A correct evaluation of presence of lymph node metastases was made by tomography in 44 of the patients. Lack of tissue diagnosis at tomography makes mediastinoscopy better as a staging procedure. Oblique hilotomography is mainly indicated as a method for accurate evaluation of the questionably large hilum.

Vascularization and tumour volume estimations of solitary liver tumours in rats.

Tumour vascularity of a transplantable N-methyl-N-nitrosoguanidine induced adenocarcinoma of the colon in the liver was investigated by repeated hepatic arteriography and portography. The arterial vascularity was influenced by tumour size; a transient increase in vascularization was observed when tumour size increased. Portography revealed portal vessels concentrated to the peripheral parts but some portal vessels were also observed leading to the central part of the adenocarcinomas. The tumour volume of solitary adenocarcinoma in the liver could be estimated from measurements of the largest (a) and smallest (b) diameters on the angiogram according to the formula V = a x b2/2.

Ultrasonography of the gallbladder. Investigation of the nonvisualized gallbladder at oral cholecystography.

One hundred and one patients with nonvisualized gallbladder at double dose oral cholecystography were examined with ultrasonography. In 41 of 44 operated patients, ultrasonography suggested gallbladder disease. Operation in all of these cases confirmed the diagnosis. In three of the patients with cholelithiasis operation revealed in addition gallbladder carcinoma. In three patients, in which ultrasonography demonstrated normal appearance of the gallbladder surgery revealed chronic cholecystitis and stone impacted in the cystic duct. The diagnostic value of ultrasonography as complementary method for evaluation of gallbladder disease, particularly in cases of nonvisualization of the gallbladder at ultrasonography is stressed. The high incidence of gallbladder carcinoma in the present material in patients with cholelithiasis point to the fact that this group of patients should be the subject for careful investigation.