Metaphyseal histology and magnetic resonance imaging in Legg-Calvé-Perthes disease

Cylindrical biopsy specimens from the proximal femoral metaphysis were obtained in conjunction with surgery in 22 patients with Legg-Calvé-Perthes disease. The histopathological examination revealed fat necrosis, vascular proliferation, and focal fibrosis indicating previous episodes of ischemia. There was no correlation between the histopathological findings and the corresponding magnetic resonance images.

Intracapsular pressure and loosening of hip prostheses. Preoperative measurements in 18 hips

We measured the intracapsular pressure preoperatively in 18 hips (17 patients) before revision of a total hip arthroplasty because of aseptic loosening. Distension of the joint capsule was measured with sonography in 13 cases. In extension, the mean intracapsular pressure was 26 (0-60) mmHg, in extension and inward rotation it was 159 (24-280) mmHg, in extension and outward rotation it was 30 (3-67) mmHg and in 45 degrees of flexion it was 12 (0-28) mmHg. A mean of 6 (0.5-20) mL of joint fluid was aspirated after the pressure measurements. Sonography showed increased joint fluid/synovial edema and/or increased capsular thickness, as compared to 34 unrevised, radiographically not loose prosthetic hips, and that the capsular distension correlated to intracapsular pressure during extension and inward rotation. We conclude that the intracapsular pressure usually is elevated in a hip joint with loose prosthetic components, that the intracapsular pressure varies with the position of the hip and that capsular distension reflects increased intracapsular pressure. The increased and often very high pressure, varying during gait, may pump debris away from the joint along the interfaces and even by itself cause osteolysis and loosening.

Fusion or stabilization alone for acute distractive flexion injuries in the mid to lower cervical spine?

Long-term pain problems and residual restricted mobility were evaluated for patients sustaining acute distractive flexion injuries to the cervical spine. To assess which of two alternative surgical approaches gives better long-term outcomes, 58 patients were studied, 29 in each group. The results of posterior wire stabilization without fusion according to Brandt were contrasted with those of the Cloward technique. We found significantly more late pain problems and restricted neck mobility in the group treated with wiring without fusion than in those managed with anterior fusion. We conclude that this continuing pain may be due to residual mobility in the damaged degenerated non-fused motion segment, and that the difference between the two groups may reflect the difference in the quality and rate of fusion achieved by the two surgical approaches.

Increased levels of proteoglycan fragments and stromelysin in hip joint fluid in Legg-Calvé-Perthes disease

The concentrations of proteoglycan fragments and stromelysin were analyzed in joint aspirates in 19 children with Legg-Calvé-Perthes disease. We found increased levels of proteoglycan fragments and stromelysin consistent with the presence of synovitis, an important clinical and possibly also prognostic factor in these children.

MR imaging as the primary modality for neuroradiologic evaluation of the lumbar spine. Effects on cost and number of examinations

PURPOSE

To evaluate the effects on cost, and number of primary and supplementary neuroradiologic examinations, after introducing MR imaging as the primary modality in the evaluation of the lumbar spine.

MATERIAL AND METHODS

Two 5-month periods were compared: period 1--before MR; and period 2--after introduction of a 2nd MR device. In period 1, patients were examined with myelography and/or CT after referral from specialists only, whereas in period 2 both specialists and general practitioners could refer patients for MR imaging. The direct cost (neuroradiologic methods and hospitalization) and indirect cost (sick-leave and estimated loss of production caused by the diagnostic procedure) were estimated.

RESULTS AND CONCLUSION

In period 1, investigations were started in 75 patients (62 myelographies and 13 CT examinations); in period 2, in 227 patients (198 MR, 21 CT, and 8 myelographies). The estimated total cost increased from SEK 825,000 to 1,265,000 (53%), the cost per investigated patient decreasing from 11,000 to 5565 (50%), and the cost of preoperative investigation per operated patient decreasing from 8616 to 5563 (35%). The number of supplementary examinations was unchanged.

Polyethylene wear in Scanhip arthroplasty with a 22 or 32 mm head: 62 matched patients followed for 7-9 years

We measured radiographic polyethylene wear in patients with Scanhip arthroplasty and no clinical or radiographic signs of loosening. The patients were divided into 2 groups according to head sizes. 32 patients (33 hips) had an implant with a 22 mm and 30 patients (34 hips) with a 32 mm head. They were followed for 7-9 years. The groups were matched for diagnosis, sex, weight, age, and time of follow-up. The mean linear wear with a 22 mm head was 1.1 mm and with a 32 mm head 1.5 mm (p 0.004), which corresponds to a yearly wear rate of 0.15 mm and 0.18 mm, respectively. The mean difference in volumetric wear was greater, 420 mm3, as compared to 1239 mm3.

Growth in 110 children with Legg-Calve-Perthes' disease: a longitudinal infancy childhood puberty growth model study

Growth in 110 children with Legg-Calve-Perthes' disease (LCPD) was longitudinally followed throughout the growth period. The infancy childhood puberty (ICP) growth model, which has the advantage that reference values can be adjusted for the individual age at pubertal maturation, was used. On the average, the children were slightly shorter at birth and they remained short throughout the entire growth period to maturity. At maturity, the boys were 4.4 cm and the girls were 2.5 cm below the reference mean. The growth velocity was normal at the time of diagnosis, prepubertally, and during puberty. Boys and girls differed only in that the boys were more overweight.

The effect of arthrocentesis in transient synovitis of the hip in the child: a longitudinal sonographic study

Twenty-one children with transient synovitis of the hip were treated in two consecutive groups. In 12 patients aspiration of the synovial effusion was performed within 24 h of admission. In a second group of nine patients no aspiration was performed. There was no other difference in treatment. Joint effusion was studied sonographically in comparison with the nonsymptomatic contralateral hip. Sonography was performed immediately after admission, within 12 h after aspiration, and repeatedly during a follow-up period of up to 15 days. Following aspiration the capsular distention decreased to 49% but recurred within 24 h to 72% of the preoperative value. However, during the first 4 days of follow-up the capsular distention in the aspirated cases was significantly and permanently lower than in the nonaspirated cases. We conclude that arthrocentesis in the acute stage of transient synovitis of the hip in the child permanently reduces the intracapsular effusion.

Measurement accuracy in acetabular cup wear. Three retrospective methods compared with Roentgen stereophotogrammetry

The accuracy of three methods (the simple and noncomputerized Scheier-Sandel and Charnley-Duo methods and the computerized Ein Bild Roentgen Analyse [EBRA] method) for retrospective wear measurements of the acetabular cup from standard pelvis radiographs was studied. Measurements on 13 hip prostheses were compared with those obtained by roentgen stereophotogrammetry analysis. The Scheier-Sandel method had the lowest accuracy and the EBRA method had the best accuracy. The Charnley-Duo method was almost as good when starting analysis 3 months after surgery and is easier to use. The EBRA method is useful for accurate measurements on a small number of patients; the Charnley-Duo method is recommended for clinical wear studies on a larger number of patients.

Intracapsular pressure and pain in coxarthrosis

Intracapsular hip pressure was measured before surgery in 17 patients (18 hips) with coxarthrosis. The results were correlated to pain as registered on a visual analog scale. With the hip in extension, the pressure was 49.5 mmHg (SD, 40.2); in 45 degrees of flexion, it was 21.3 mmHg (SD, 14.6); in extension and inward rotation, it was 105.7 mmHg (SD, 76.0); and in extension and outward rotation, it was 40.8 mmHg (SD, 32.0). A small amount, 0.7 mL (SD, 1.14), of joint fluid was aspirated following pressure registration. Pressure correlated significantly to pain at night, when starting to walk, and on walking. It is suggested that the increase in intracapsular hip pressure is a cause of pain in coxarthrosis, with subsequent limitation of movement and joint contracture.

Sonography and intracapsular pressure in Perthes' disease. 39 children examined 2-36 months after onset

39 children with Legg-Calvé-Perthes Disease (LCPD) and with a radiographically unsatisfactory development were examined with sonography regarding synovitis and with intracapsular pressure recording and aspiration performed 15 (2-36) months after the onset of symptoms. The mean anterior sonographic capsular distension was 3.0 (1.0-7.0) mm greater than that of the contralateral, asymptomatic hip. The mean intracapsular pressure was 4.5 (0-11.5) kPa with the hips in extension and neutral rotation, 9.7 (1.3-27.3) kPa with the hips in extension and inward rotation and 0.9 (-0.8-4.7) kPa in 45 degrees of flexion. We conclude that these children have synovitis as diagnosed sonographically. This synovitis is probably symptomatically and prognostically important in LCPD due to increased intracapsular pressure, with pain, a decreased range of motion and, potential joint contracture.

Femoral head shape in Legg-Calvé-Perthes disease. Correlation between conventional radiography, arthrography and MR imaging

Twenty-three children with Legg-Calvé-Perthes disease were examined to determine the femoral head shape. We evaluated and correlated conventional radiography, arthrography and MR imaging. In the a.p. view, measurements were obtained from the center of the femoral head along the bony or cartilaginous outline at 30 degrees intervals. Maximum flattening of the cartilaginous outline appeared laterally, 60 degrees from the center of the baseline of the epiphyseal index and the caput index. Maximum flattening of the bony outline was found at 75 degrees. Arthrography and MR imaging gave the same information about the shape of the femoral head cartilage. The bony femoral head shape on conventional radiographs in the a.p. view did not reflect the cartilage shape obtained by MR and arthrography.

Prospective comparison of hip fracture treatment. 856 cases followed for 4 months in The Netherlands and Sweden

In a prospective multicenter study 1115 hip fracture patients were registered in Rotterdam (The Netherlands), Sundsvall and Lund (Sweden). The patients had similar background parameters with a mean age of 78 years, about half of them living alone and just above 80 percent coming from independent living. For cervical fracture, hemiarthroplasty was the predominating treatment in Rotterdam (n 169), whereas osteosynthesis was used in Sundsvall (screws n 135) and Lund (hook-pins n 148). The mean (median) hospitalization time was 32 (20) days in Rotterdam, 16 (12) days in Sundsvall, and 17 (10) days in Lund. Discharge to independent living varied from 53 percent in Lund to 72 percent in Sundsvall. Functional outcome (walking ability and ADL capacity) was at 4 months similar in all groups, but at 2 weeks was lower in Rotterdam. Mortality at 2 weeks/1 month/4 months was in Rotterdam 4/9/20, in Sundsvall 2/4/13, and in Lund 0/3/10 percent. Trochanteric fractures were treated by screwplate in Rotterdam (n 146) and Lund (n 78), and by Ender nails in Sundsvall (n 117). The mean (median) hospitalization time was in Rotterdam 39 (29) days, in Sundsvall 24 (15) days and in Lund 19 (11) days. Discharge to independent living varied from 41 percent in Lund to 57 percent in Sundsvall. Functional outcome was similar between the groups. Mortality at 2 weeks/1 month/4 months was in Rotterdam 2/6/14, in Sundsvall 6/12/19 and in Lund 12/12/18 percent. Thus, our study has shown that it is possible to perform a prospective multicenter study involving different European countries.(ABSTRACT TRUNCATED AT 250 WORDS)

The prevalence of gonarthrosis and its relation to meniscectomy in former soccer players

The prevalence of radiographic signs of gonarthrosis and its relation to knee injuries were studied in 286 former soccer players--215 nonelite and 71 elite players--and were compared with 572 age-matched controls with a mean age of 55 years. The prevalence of gonarthrosis among the nonelite players was 4.2%, among the elite players 15.5%, and among the controls 1.6%. Seven of the soccer players had known anterior cruciate ligament injuries, and 40 had had meniscectomies. Of the 32 nonelite players with knee injuries, 4 (13%) had gonarthrosis, and of the 183 without known knee injuries 5 (3%) had gonarthrosis. Among the elite players, the prevalence of gonarthrosis in knees without diagnosed injuries was 11%. We conclude that soccer, especially at an advanced level, is associated with an increased risk for gonarthrosis. After excluding subjects with known knee injuries, there was no difference between nonelite players and controls, but we found a higher rate of gonarthrosis among the elite players.

Size of osteonecrosis of the knee

In the Swedish Multicenter Study of Knee Arthroplasty, 115 knees in 110 patients with knee osteonecrosis represented all reported cases treated with knee arthroplasty in the period from 1975 to 1986. Primary medial femoral condyle osteonecrosis was the most common osteonecrosis reported (89%). Preoperative roentgenograms were staged according to the type of osteonecrosis and classified according to the grade of arthrosis. Detailed measurements of the size of the lesion were also performed. For primary medial femoral osteonecrosis, the width of the lesion averaged 45% of the condyle. The mean width of the lesion (anteroposterior size) was 21 mm and the mean length (lateral size) was 34 mm. The mean depth on lateral roentgenograms was 6 mm. There was a high correlation of results among the various methods of measurement. Using regression analysis, it was possible to approximate the volume of the lesion even from a single measurement of the width on anteroposterior view. The size of osteonecrosis of the knee can be used to plan resection and select the implant design.

Treatment of hip fracture in Finland and Sweden. Prospective comparison of 788 cases in three hospitals

A prospective population-based study of hip fracture treatment was performed during 1989 in the regional hospitals of Oulu (Finland) and Sundsvall and Lund (Sweden). For cervical fractures hemiarthroplasty was preferred in Oulu and osteosynthesis in Sundsvall and Lund. For trochanteric fractures screw-plate was preferred in Oulu and Lund and Ender-nailing in Sundsvall. A shorter mean time at the orthopedic department in Oulu (13 days) was compensated by a lower (14 percent) fraction of patients directly discharged to own home. A somewhat longer mean orthopedic hospitalization time in Sundsvall (19 days) and Lund (17 days) was combined with a higher discharge to own home (49 percent and 35 percent). Prospective multicenter comparisons of treatment combinations (both operation and rehabilitation) permit identification of programs that are optimal for both patient and society.

CT of the wrist in suspected scaphoid fracture

Bone scan and sagittal projection CT of the scaphoid was performed in 10 patients with clinically suspected scaphoid fractures. The primary and follow-up plain radiographs were negative or equivocal for fracture. CT examination demonstrated scaphoid fracture in 7 patients and normal findings in 3. It is concluded that CT of the scaphoid can replace bone scan to diagnose or rule out fracture in institutions where nuclear medicine facilities are not available.

Primary osteonecrosis in the knee evaluated by histopathology and specimen scintimetry related to clinical radiography, scintimetry and MR

Arthroplasty for primary osteonecrosis of the femoral condyle of the knee was performed in 5 patients and the resected pieces of bone were studied histologically. The patients had been given 99 mm-Tc-MDP preoperatively and the scintimetric uptake in the resected bone pieces was determined. All patients had changes typical for osteonecrosis preoperatively on radiographs and scintimetry. In one case MRI investigation was performed. The histological investigation showed necrotic bone with empty lacunae and fatty degeneration corresponding to the osteonecrosis center. A reparative bone formation, osteoblastic activity, cartilage formation and bands of fibrovascular granulation tissue were observed at the borders to intact bone. The scintimetric uptake of the resected bone pieces showed a high uptake corresponding to the osteonecrosis center. The MR examination showed a well demarcated osteonecrotic region. The findings emphasize the localized nature of the osteonecrosis disease.

Measurement accuracy in acetabular cup migration. A comparison of four radiologic methods versus roentgen stereophotogrammetric analysis

Four different methods of radiologic evaluation of the acetabular component migration following total hip arthroplasty have been compared with roentgen stereophotogrammetry, a proven highly accurate method for studying early migration. In the Sutherland and Wetherell method the implant's position is measured with a pencil and a ruler from an ordinary pelvis radiograph. New reference lines of the Wetherell method are thought to be more accurate. The Sulzer and EBRA methods are computerized. In the Sulzer method prominent bone markers are digitized and used as reference points. In the EBRA method a system of tangents on prominent pelvis structure is digitized and used to detect radiographs with similar projection. The implant's position is calculated as the mean position of similar radiographs. The Sutherland, Wetherell, and Sulzer methods had almost the same accuracy, whereas the EBRA method was more accurate and could be used for pro- and retrospective studies in a large number of patients.