Opioid analgesics versus ketorolac in spine and joint procedures: impact on healthcare resources

BACKGROUND

Ketorolac's efficacy as a postoperative analgesic has been shown to be comparable to that of narcotic analgesics, but with significantly fewer narcotic-related adverse events.

OBJECTIVE

To assess whether the choice of postoperative analgesic, narcotic or ketorolac, has an impact on healthcare resource utilization and cost durng inpatients' recovery period.

DESIGN

Retrospective, multicenter, controlled, parallel, cost-minimization analysis.

SETTING

Six US teaching hospitals.

PATIENTS

This study included 559 patients that underwent either a spine or joint procedure and received adequate doses of narcotic (n = 284 of either morphine or meperidine) or ketorolac (n = 275).

MEASUREMENTS

Time to reach recovery milestones, average utilization of healthcare resources, and average per-case postoperative treatment cost.

RESULTS

Several recovery milestones, including time to first bowel movement, first oral intake, and first unassisted ambulation, were reached sooner in the ketorolac group, with a resultant shorter mean length of postoperative stay (narcotic 3.78 d, ketorolac 2.80 d; p = 0.01). Total per-patient cost of treatment was 32% greater in the narcotic group, resulting primarily from higher costs associated with hospitalization.

CONCLUSIONS

Despite the higher acquisition cost of medication, healthcare resource utilization and total per-patient cost of treatment were lower for patients in the ketorolac group compared with patients in the narcotic analgesic study group. The majority of patients in the ketorolac group were also given concurrent narcotic analgesics; therefore, the beneficial effects observed may be secondary to the combination of ketorolac and narcotic analgesics.

Engineered cartilage, bone, joints, and menisci. Potential for temporomandibular joint reconstruction

Reconstruction of many musculoskeletal structures can be accomplished by bone grafting and implantation of prostheses. Alternate approaches are needed, however, for repair of complex structures such as articular cartilage surfaces and the temporomandibular meniscus and joint. Tissue engineering, either cell-free or cell-based, offers promise because of recent advances in materials research and in our knowledge of the cellular and molecular mechanisms of tissue repair. There are three considerations in designing a construct for engineered tissue: the source of cells, if any; the nature of the carrier or scaffold; and use, if any, of genes, factors, or adjuvants. Autogenous cells, often expanded in vitro, have been useful for cartilage tissue engineering. Precursor/progenitor cells are advantageous for bone tissue. There are many natural and synthetic resorbable materials with good biocompatibility and tissue compatibility that can be modified to have the porosity and mechanical properties needed for specific applications. The scaffolds can also be modified to provide biological signals to augment repair and integration.

Bioabsorbable implants in orthopaedics: new developments and clinical applications

The use of bioabsorbable implants in orthopaedic surgical procedures is becoming more frequent. Advances in polymer science have allowed the production of implants with the mechanical strength necessary for such procedures. Bioabsorbable materials have been utilized for the fixation of fractures as well as for soft-tissue fixation. These implants offer the advantages of gradual load transfer to the healing tissue, reduced need for hardware removal, and radiolucency, which facilitates postoperative radiographic evaluation. Reported complications with the use of these materials include sterile sinus tract formation, osteolysis, synovitis, and hypertrophic fibrous encapsulation. Further study is required to determine the clinical situations in which these materials are of most benefit.

TGF-beta1 as a prognostic factor in the process of early osteoarthrosis in the rabbit knee

OBJECTIVE

To assess changes in knee joint fluid concentrations of transforming growth factor-beta1 (TGF-beta1) and proteoglycan (PG) fragments during the early course of post-traumatic osteoarthrosis (OA) after meniscectomy in the rabbit knee, and to ascertain whether the concentrations of these substances shortly after operation could be used as prognostic markers for the OA process.

DESIGN

In 15 rabbits with medial meniscectomy in one knee and a sham operation in the other knee, synovial lavage fluid samples were taken repeatedly, before operation, every third week post-operatively until 12 weeks, thereafter every sixth week, and at death. Five rabbits each were killed at 13, 25 and 40 weeks. Synovial lavage fluid samples from five non-operated rabbits served as controls. At death, two histological scores were formed that characterized the highest (MAX) and the overall (ALL) degree of OA changes in each joint.

RESULTS

TGF-beta1 and PG fragment concentrations in synovial lavage fluid correlated highly (R=0.81, P< 0.001). Both OA scores were higher in meniscectomized than controls (P< 0.05). The synovial lavage fluid concentration of TGF-beta1 at 3 weeks, but no other time point, correlated to the histological scores (ALL, R=0.58; MAX, R=0.52;P< 0.001).

CONCLUSION

Higher concentrations of TGF-beta1 in synovial lavage fluid early after surgery seemed indicative for the later development of more severe OA changes in contrast to lower concentrations. The association between TGF-beta1 and the changes found later in the cartilage was underlined by the high correlations between this substance and PG fragment concentrations in synovial lavage fluid at all time points.

Evaluation of very low-dose subcutaneous vitamin K during postoperative warfarin therapy

STUDY OBJECTIVE

To determine the effect of very low-dose subcutaneous vitamin K (SCVK) compared with withholding warfarin for above-target international normalized ratio (INR) values after joint surgery.

DESIGN

Historical controlled study.

SETTING

University hospital.

SUBJECTS

One hundred thirty-nine patients beginning warfarin after total joint surgery.

INTERVENTION

For a high INR, warfarin was either withheld or SCVK 100, 300, or 400 microg was administered, depending on INR value.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was change in INR from the day of intervention (day 1) to the next day (day 2). Adjusting for day 1 INR, the mean day 2 INR was 2.10 (95% confidence interval [CI] 1.86-2.33) after SCVK, compared with 2.73 (95% CI 2.50-2.96) in controls. This corresponded to declines of -0.72 and -0.08, respectively (p=0.001).

CONCLUSION

In orthopedic patients starting warfarin therapy, very low-dose SCVK was more effective than withholding warfarin in reducing high INRs. Investigations in other populations and assessment of the effect of low-dose SCVK on postoperative bleeding are indicated.

Factors affecting nonunion of the allograft-host junction

Nonunion of allograft-host junction after bone transplantation is not uncommon, and its treatment frequently is problematic. To improve the understanding of these nonunions, a retrospective review was performed of 163 nonunions in 945 patients who underwent allograft transplantation (17.3%) for various benign and malignant tumors at the authors' institution between 1974 and 1997. Of these 945 patients, 558 did not receive adjuvant therapy. Chemotherapy was administered to 354 patients and only 33 patients received radiation therapy alone. Seventy-one patients had radiation treatment and chemotherapy. Of the 163 patients who had nonunion develop at the allograft-host junction, there were 269 reoperations performed on the involved extremity. In 108 patients, treatment was successful resulting in union of the allograft-host junction. Forty-nine patients did not respond to multiple surgical treatment attempts. The greater the number of surgical procedures, the worse the outcome. The rate of nonunions increased to 27% for the patients who received chemotherapy as compared with 11% for the patients who did not receive chemotherapy. The order of allografts from highest rate of nonunion to lowest was as follows: alloarthrodesis, intercalary, osteoarticular, and alloprosthesis. Infection and fracture rates were higher in the patients with nonunions as compared with the patients without nonunions.

Allograft fractures revisited

A retrospective review of patients with allograft fractures was done at the authors' institution. Between 1974 and 1998, 185 of 1046 (17.7%) structural allografts fractured in 183 patients at a mean of 3.2 years after transplantation. Initial allograft fixation included internal fixation with plates and screws in 181 patients. Patients with grafts that were longer than the average length (15.5 cm) tended to have worse results. Adjuvant therapy had no effect on fracture rate. Seventy-three patients with fractures had other allograft complications. Infection and nonunion with allograft fracture significantly worsened the outcome. The incidence of fracture in the patients with osteoarticular and arthrodesis transplants was significantly higher than those patients who had intercalary and composite reconstructions. Treatment of the allograft fractures included open reduction and internal fixation in 41 patients, reconstruction with a new allograft in 38, allograft-prosthesis composite in five, oncologic prosthesis in 19, amputation in 15, arthroscopic removal of loose bodies in three, resurfacing of fractured osteoarticular allograft surfaces in 39, allograft removal and cement spacer placement in 15. Twenty patients did not receive treatment. Eight of the fractures in patients who were not treated healed spontaneously. Outcomes were judged as excellent in nine patients (4.9%), good in 72 patients (38.9%), fair in 17 patients (9.2%), and in 85 patients (45.9%) the allograft reconstruction failed.

Evaluation of a canine total-elbow arthroplasty system: a preliminary study in normal dogs

OBJECTIVE

Short-term, in vivo evaluation of a total-elbow arthroplasty (TEA) system in normal dogs.

STUDY DESIGN

Prospective evaluation comparing pre- and postoperative findings.

ANIMALS

Six normal, skeletally mature, large-breed dogs.

METHODS

Physical, radiographic, and force-plate gait examinations were performed on all dogs before surgery. TEA was performed in the dogs using a canine TEA system. Examinations were repeated every 8 weeks for 24 weeks, with an additional examination at 52 weeks. Pre- and postoperative findings were compared.

RESULTS

The TEA led to an excellent outcome in 3 of 6 dogs. Force-plate gait examination found that the dogs continued to improve over time and had a peak vertical force (PVF) in the surgical limb that was 99.6% of normal (range, 95.8% to 106.4%) 52 weeks after surgery. Major problems encountered during the postoperative time period were non-weight-bearing lameness (1 dog), osteomyelitis (1 dog), and fracture of the ulna (1 dog).

CONCLUSIONS

TEA can be successfully performed in dogs.

CLINICAL RELEVANCE

Based on 1-year data, TEA can be successfully performed in dogs and could be considered as a treatment alternative for adult dogs with severe osteoarthritis and lameness of the elbow joint.

Cartilaginous extracellular matrix of failed massive osteoarticular allografts

Osteoarticular defects present a reparative challenge to orthopaedic surgeons. Osteoarticular allografts provided a promising solution. Unfortunately, many of these allografts failed secondary to articular cartilage degeneration. To determine the role of the extracellular matrix in graft failure, the authors have characterized the proteoglycan content of cartilage from grafts that failed early (2-4 years) and grafts that failed late (approximately 8 years) and compared this with normal cartilage. Cartilage was removed from all specimens. Proteoglycans were extracted and characterized based on molecular size and reactivity with antibodies. Protein and proteoglycan contents of early and late failure grafts were significantly lower per gram of tissue than normal cartilage. Patterns of distribution of associated proteoglycans and dissociated proteoglycans differed between early and later failure grafts and both were different from normal cartilage. Early failure cartilage contained less keratan sulfate proteoglycan with a different distribution of molecular sizes. Chondroitin sulfate epitopes showed discordance between early failure and normal cartilage and concordance between normal and late failure cartilage. These data show distinct differences in proteoglycan content between failed graft and normal cartilage and also between cartilage from grafts that failed early and late. Proteoglycan content and glycosaminoglycan substitution were altered in all specimens. Maintenance of a more normal extracellular matrix will be required to preserve function in these grafts for longer periods.

Diagnostic findings and prognosis following arthroscopic treatment of subtle osteochondral lesions in the shoulder joint of horses: 15 cases (1996-1999)

OBJECTIVE

To determine clinical, scintigraphic, radiographic, and arthroscopic findings and results of treatment in horses with lameness attributable to subtle osteochondral lesions of the shoulder joint.

DESIGN

Retrospective study.

ANIMALS

15 horses.

PROCEDURE

Medical records were reviewed, and results of physical examination, scintigraphy, radiography, arthroscopy, and treatment were recorded.

RESULTS

Severity of lameness ranged from grade 1 to 4. Response to shoulder flexion or extension was variable. Twelve horses had a narrow upright foot. Intra-articular anesthesia of the shoulder joint localized the cause of the lameness to the shoulder joint in 9 of 10 horses. Scintigraphic abnormalities were detected in 4 of 6 horses. Radiographic lesions were subtle and included glenoid sclerosis, focal glenoid lysis, small glenoid cysts, and alterations in the humeral head contour. Arthroscopic evaluation confirmed clefts in the glenoid cartilage, glenoid cysts, a humeral head cyst, fibrillation of the humeral head cartilage, cartilage fragmentation, or a nondisplaced fracture of the humeral head. After treatment, 12 horses returned to their previous level of performance, 1 was sound for light riding, 1 remained lame, and 1 was euthanatized because of chronic lameness.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that a combination of physical examination, scintigraphy, and radiography is necessary to diagnose subtle osteochondral lesions of the shoulder joint in horses. Arthroscopy can be used to confirm the diagnosis and treat cartilage and subchondral bone lesions. Young and middle-aged horses with subtle osteochondral lesions of the shoulder joints have a good prognosis for return to performance following arthroscopic treatment.

The influence of transforming growth factor beta1 on mesenchymal cell repair of full-thickness cartilage defects

To repair full-thickness articular cartilage defects in rabbit knees, we transplanted periosteal cells in a fibrin gel and determined the influence of transforming growth factor beta (TGF-beta) in vitro. Alginate served as a temporary supportive matrix component and was removed prior to transplantation. The defects were analyzed macroscopically, histologically, and electron microscopically, and evaluated with a semi-quantitative score system. Periosteal cell transplants showed a chondrogenic differentiation, which results in the development of embryonic-like cartilage tissue after 4 weeks and complete resurfacing of the patellar groove after 12 weeks. In the control groups, no repair was observed. Under the influence of TGF-beta1 we observed a reduction of the cartilage layer, whereas the osteochondral integration and the zonal architecture were improved. Periosteal cell-beads are stable cartilage transplants and have stiffness and elasticity enough for easy and sufficient transplant fixation. Further investigations are necessary to optimize the application of TGF-beta1 for cartilage repair.

Osteochondral reconstruction of a non-weight-bearing joint using a high-density porous polyethylene implant

Currently, there is no reliable reconstructive modality allowing anatomic resurfacing of traumatic digital osteochondral articular defects. The purpose of the present study is to demonstrate the utility of Medpor, a high-density porous polyethylene (HDPP) scaffold biomaterial that can (1) be readily contoured to fit any joint defect, (2) permit stable internal fixation, and (3) permit osteocyte and chondrocyte ingrowth and subsequent articular cartilage resurfacing necessary to restore joint congruity. HDPP has gained wide acceptance for use in craniofacial and skeletal reconstruction and augmentation. An avian non-weight-bearing joint model was designed to study the role of the HDPP implant in small joint reconstruction. An osteochondral defect was created with a 5-mm circular punch in the humeral articular surface of both glenohumeral joints of 32 adult White Leghorn chickens. In each animal, one defect was press-fitted with a correspondingly sized HDPP implant (HDPP implant group); the contralateral defect was filled with the original osteochondral plug (isograft group) or left unrepaired (control group). At 2 weeks, and 1, 3, and 6 months,joints from each group were harvested and evaluated. Over the 6-month study period, joints in the control group demonstrated healing with dense collagenous scar tissue leaving residual defects at the articular surfaces and significant degenerative disease of the glenohumeral joints radiographically. Joints in the isograft group demonstrated near-complete resorption with some preservation of the cartilaginous cap but overall depression of the articular surface and significant degenerative joint disease. Joints in the HDPP implant group demonstrated stable fixation by highly mineralized bony trabecular ingrowth, preservation of the articular contour of the humeral head, and no evidence of significant degenerative joint disease. These findings indicate a potential role for this high-density porous polyethylene implant in the reconstruction of small joint articular and osseous defects.

A long-term follow-up study of cervical lesions in rheumatoid arthritis

To determine the natural history of cervical lesions in rheumatoid arthritis, 161 patients who had been followed for a minimum of 5 years were enrolled in this study. The average follow-up period was 10.2 years (range, 5 to 20 years). The severity of the rheumatoid arthritis was classified into three types based on the multiplicity of peripheral joint rheumatoid involvement: a least erosive subset, a more erosive subset, and a mutilating disease subset. Ninety-two patients (57%) had upper cervical involvement, which progressed in the order of anterior atlantoaxial subluxation, anterior atlantoaxial subluxation combined with vertical subluxation, and vertical subluxation alone. Subaxial subluxation was found in 18 patients (11%). In 17 of these 18 patients, upper cervical lesions were also noted. The incidence of cervical involvement in each disease subset was 39% in the least erosive group, 83% in the more erosive group, and 100% in the mutilating disease group. Fifty percent of the patients with cervical involvement had neck pain, and the remaining patients were asymptomatic. Neural involvement occurred in 10 patients. In 7 of these 10 patients, vertical subluxation of the atlas was responsible for the neural deficit. Six patients required surgical intervention because of progressive myelopathy.

Removal of the lateral or medial third of patellar tendon alters the patellofemoral contact pressure and area: an in vitro experimental study in dogs

OBJECTIVES

To compare patellofemoral contact pressure and areas after immediate removal of the lateral, central, or medial third of patellar tendon.

DESIGN

In vitro experiment in 12 dogs.

BACKGROUND

Alteration of the vector sum of the quadriceps muscle contraction after removal of partial patellar tendon might result in changes of patellar tracking in the trochlea.

METHODS

Patellofemoral contact pressure and areas were recorded using Fuji pressure-sensitive film at 45 degrees, 60 degrees, and 90 degrees of knee flexion under an isometric quadriceps force of 100% body weight. The patellofemoral contact imprint from the intact knees were obtained as control, and the lateral (n=4), central (n=4), and medial (n=4) third of the patellar tendon were subsequently removed and the patellofemoral contact imprint was recorded.

RESULTS

The patellofemoral contact area was found to increase with increasing knee flexion angles. No change in patellofemoral contact pressure and areas was found after removal of the central third patellar tendon. However, after removal of either lateral or medial third of patellar tendon, the patellofemoral contact was rotated with increasing knee flexion angles. This was due to the altered vector sum of the quadriceps force, resulting in significantly decreased patellofemoral contact areas and simultaneously a significantly increased contact pressure, characterized with concentration of patellofemoral contact pressure on both lateral and medial facets of the patellofemoral joint.

CONCLUSIONS

The results suggest that removal of the central third of patellar tendon may not alter the patellofemoral contact pressure and areas as compared with removal of either lateral or medial third of patellar tendon that may result in an altered postoperative tracking mechanism of the patellofemoral joint immediately after operation.

RELEVANCE

Findings of this in vitro animal study supports the use of central third of patellar tendon as autograft for anterior cruciate ligament reconstruction. However, further experimental studies are needed to investigate how the postoperative healing of the host patellar tendon will influence the findings obtained from this in vitro study.

Reduction of humeroulnar congenital elbow luxation in 8 dogs by using the transarticular pin

The purpose of this study was to evaluate the clinical and radiographic outcome in 8 dogs of surgical reduction of congenital humeroulnar luxation by using the transarticular pin. Five cases were bilateral and 3 were unilateral, for a total of 13 elbows. The treatment was performed in animals between 45 and 150 days of age. Articular stabilization was achieved by using a transarticular pin driven from the caudal aspect of the olecranon into the body of the humerus or into the distal condyle and distal metaphysis of the humerus. The follow-up period was between 1 and 19 months. There were 5 postsurgical reluxations, 3 related to the insertion of the pin into the humeral condyle and 2 related to the insertion into the humeral body. These animals needed further surgery. Six animals showed near normal return to limb function and 2 had lameness. We conclude that the use of the transarticular pin is an effective and simple method for the treatment of humeroulnar congenital elbow luxation.

Qualitative and quantitative documentation of the racing performance of 461 Thoroughbred racehorses after arthroscopic removal of dorsoproximal first phalanx osteochondral fractures (1986-1995)

The purpose of this study was to examine the longevity of postoperative careers and quality of performance of 461 Thoroughbred racehorses after arthroscopic removal of dorsoproximal first phalanx (P1) osteochondral fractures. Six hundred and 59 dorsoproximal P1 chip fractures were removed arthroscopically from 574 joints in 461 horses presented for lameness or decreased performance attributed to the chip fractures. Radiological and arthroscopic examination revealed an average of 1.43 fragment sites/horse, 1.15 fragment sites/joint and 1.25 affected joints/horse. Eighty-nine percent of the horses (411/461) raced after surgery and 82% (377/461) did so at the same or higher class. Fifty horses did not race after surgery. Sixty-eight percent of the horses raced in a Stake or Allowance race postoperatively. Data, previously undocumented, establishes that the quantity and quality of performance is not diminished after arthroscopic treatment of dorsoproximal P1 fragmentation. Surgical removal of chip fractures is a means of preserving the economic value of an injured Thoroughbred, allowing a rapid and successful return to racing at the previous level of racing performance.

Degenerative changes at the scaphotrapezial joint following Herbert screw insertion: a radiographic study comparing patients with scaphoid fracture and primary hand arthritis

One method of Herbert screw insertion is to mobilize the scaphotrapezial joint and insert the screw through the articular surface of the distal scaphoid. Because of concern that this might predispose to osteoarthritis in the scaphotrapezial joint, we have investigated joint space width and the presence of osteophytes adjacent to the scaphotrapezial joint using high definition macroradiography.Twenty-eight patients with symptomatic primary osteoarthritis of their hands, 23 with a scaphoid fracture successfully treated conservatively and 18 treated with a Herbert screw were studied. The patients with primary osteoarthritis of their hands had more narrowing of the scaphotrapezial joint compared with the other two groups, but patients treated with a Herbert screw had a significantly higher incidence of osteophytosis on the distal scaphoid than the other two groups. With Herbert screw fixation, osteophytosis on the distal scaphoid may cause impingement and pain, and be a predictor of further degenerative joint changes.

The Sauve-Kapandji procedure for post-traumatic disorders of the distal radio-ulnar joint

We present the results of a retrospective series of 41 Sauve-Kapandji procedures carried out for complications of fractures of the distal radius. All the operations were undertaken by one surgeon with a mean follow-up of 32 months. A total of 37 patients was available for clinical review. The indications for surgery were pain on the ulnar side of the wrist and decreased rotation of the forearm. Intraperiosteal and extraperiosteal techniques were used for resection of the ulna, with no difference in outcome. Patients were assessed for pain, rotation of the forearm and complications. A Mayo Modified Wrist Score was used. Pain was improved in 25 of the 37 patients, and unchanged in ten. Rotation of the forearm returned to within 7 degrees of the uninjured side. The results are discussed in relation to the presence of preoperative malunion of the distal radius, age and the functional outcome. Age is not a contraindication for this procedure.

Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain

STUDY DESIGN

A prospective audit.

OBJECTIVE

To establish the efficacy of lumbar medial branch neurotomy under optimum conditions.

SUMMARY OF BACKGROUND DATA

Previous reports of the efficacy of lumbar medial branch neurotomy have been confounded by poor patient selection, inaccurate surgical technique, and inadequate assessment of outcome.

METHODS

Fifteen patients with chronic low back pain whose pain was relieved by controlled, diagnostic medial branch blocks of the lumbar zygapophysial joints, underwent lumbar medial branch neurotomy. Before surgery, all were evaluated by visual analog scale and a variety of validated measures of pain, disability, and treatment satisfaction. Electromyography of the multifidus muscle was performed before and after surgery to ensure accuracy of the neurotomy. All outcome measures were repeated at 6 weeks, and 3, 6, and 12 months after surgery.

RESULTS

Some 60% of the patients obtained at least 90% relief of pain at 12 months, and 87% obtained at least 60% relief. Relief was associated with denervation of the multifidus in those segments in which the medial branches had been coagulated. Prelesion electrical stimulation of the medial branch nerve with measurement of impedance was not associated with outcome.

CONCLUSIONS

Lumbar medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. Adequate coagulation of the target nerves can be achieved by carefully placing the electrode in correct position as judged radiologically. Electrical stimulation before lesioning is superfluous in assuring correct placement of the electrode.

Clinical application of prong-type tissue anchors in small animal surgery

Prong-type tissue anchors were used in six dogs and one cat in a variety of orthopaedic procedures in order to aid repair and replacement of tendons and ligaments. All animals returned to normal function with minimal problems.

A technique for isolated arthrodesis for inflammatory arthritis of the talonavicular joint

There are few reports in the literature documenting the efficacy of isolated arthrodesis for inflammatory arthritis of the talonavicular joint. Accordingly, we reviewed a single surgeon's experience with this procedure in twenty consecutive cases from this patient population. A technique using indirect joint distraction and the combined use of screw and staple fixation was employed. Solid arthrodesis was noted radiographically in 19 of 20 feet (95%) at an average of 11 weeks. Complications included one non-union, one deep venous thrombosis, and one superficial wound infection. Objective results were graded as excellent in 16 cases, good in 3 cases, and poor in one case. Subjectively, 18 patients were satisfied and one patient dissatisfied with the results of the procedure. It is concluded that isolated arthrodesis is an effective procedure for the treatment of inflammatory arthritis of the talonavicular joint, offering significant pain relief and improved function. Additionally, the use of indirect joint distraction and fixation with screws and staples is a reliable technique associated with an excellent fusion rate.

The Bristol 'OA500 study': progression and impact of the disease after 8 years

OBJECTIVE

To study the natural history of peripheral joint osteoarthritis (OA) and assess its impact over eight years in a prospective study of 500 patients.

METHODS

500 consecutive patients with peripheral joint OA were recruited from a hospital-based rheumatology clinic. All were invited for review 3 and 8 years after entry. Joint sites involved, pain severity, change in index joints, global change in the condition, use of medication, surgery and walking aids were all recorded at each visit, and after eight years disability was assessed by the health assessment questionnaire (HAQ) and anxiety and depression by the Hospital anxiety and depression scale (HAD).

RESULTS

At eight-year review, 349 patients were seen: 90% of those remaining alive. Outcome was heterogeneous. Sixty patients (17.2%) reported worsening in all three subjective parameters (pain, index joint and global change) compared with 22 (6.3%) who improved in all three parameters. Using this definition of worsening or improvement, strong baseline predictors of clinical outcome did not emerge. For further description, the group was split according to the index joint sites involved at entry to the study, there being 111 with knee OA alone, 87 with hand and knee OA, 72 with hand disease alone, and 29 with hip disease alone. Forty-four percent of those with lone hand disease at entry had acquired significant knee or hip OA 8 years later. The mean HAQ and HAD scores at 8 years were high, especially in those with knee disease, indicating significant disability as a result of the disease. Those with knee or knee and hand disease had the worst outcome in all parameters recorded. The data showed a general decrease in use of NSAIDs over the eight years, but an increase in utilization of analgesics, surgery (especially for hip disease) and walking aids.

CONCLUSIONS

Patients with peripheral joint OA of sufficient severity to lead to hospital referral have a heterogeneous, but generally bad outcome over 8 years, the disease resulting in high levels of physical disability, anxiety and depression, with a high level of utilization of healthcare resources, including joint replacement, drugs and walking aids. The results were consistent with previous suggestions that peripheral joint OA in older people is characterized by the slow acquisition of new joint sites. Progression and outcome may depend on a complex set of psychosocial factors, as well as biological ones.

[Surgical treatment of carpometacarpal joint osteoarthritis of the thumb by trapeziectomy-interposition-ligamentoplasty]

INTRODUCTION

Osteoarthritis of the carpometacarpal joint of the thumb is a common pathology. Several surgical methods exist, including trapeziectomy, arthrodesis, cemented or cementless prosthesis. Therefore, one must question the legitimacy of non prosthetic surgery. The authors have tried to answer this question.

METHOD

Surgery consisted in trapeziectomy and ligament reconstruction with tendon interposition arthroplasty (LRTI). Authors reviewed 47 cases with five years follow-up. Patients were evaluated using a functional score, including pain, professional and domestic activities, and leisure involving the hand. Objective data were also assessed: thumb opposition, radiographic scaphometacarpal mobility, key and tip pinch, grasp strength.

RESULTS

Functional results ranged from good to excellent in 42 cases. Opposition was satisfactory in 46 cases. Scapho-metacarpal range of motion was 16 degrees. Pinch strength was 4.2 kg and grasp strength was 23 kg. There were no complications. Loss of pinch strength was 1 to 2 kg as compared to our reference group. Such a loss does not impair patients' daily life. Age and operated side do not influence results. Scores do not decrease with time. Radiographic staging seems to be linked with scoring. Reducing the trapezial space does not influence results. We had none of the complications described in other techniques: synovitis, ossifications, loosening and reflex sympathetic dystrophy.

DISCUSSION

This study, as well as literature, confirms that trapeziectomy and ligament reconstruction with tendon interposition arthroplasty gives satisfactory functional results which are stable with time and without complication. For all these reasons, the authors prefer this technique in degenerative osteoarthritis.

Hyperphosphatemic tumoral calcinosis

Tumoral calcinosis is a rare syndrome characterized by progressively growing and painless masses of calcium phosphate deposits within periarticular areas. Biochemical findings are normal except for an association with hyperphosphatemia. This report describes hyperphosphatemic tumoral calcinosis in a 22-year-old man who had been operated on five times in 5 years because of painless extremity swellings.

Effects of metal ions on white blood cells of patients with failed total joint arthroplasties

In this study twenty-two patients who had revision surgery for aseptic loosening of joint prostheses were examined. The concentration in serum of soluble products of corrosion from the implant, that is, chromium (Cr), cobalt (Co), and nickel (Ni) ions, and the number of white blood cells (leucocytes, myeloid cells, lymphocyte subpopulations) were measured. Twenty patients with no implants were used as controls. The patients who had revision surgery showed normal Ni concentration whereas by statistical analysis that same patient group was shown to have serum Cr and Co levels significantly higher than those of the control. By flow cytometry, a significant decrease of leucocytes, myeloid cells, lymphocytes, and CD16 populations as found in patients versus controls whereas CD3, CD4, CD8, and CD20 positive cells were decreased, but not significantly. In the arthroplasty patients the Cr concentrations were inversely correlated with some of the immunologic parameters while no significant correlation was found between Co levels and decreased lymphocyte subpopulations. Only in revision surgery patients with high Cr concentrations did we find a significant decrease of lymphocytes, namely of CD4 and CD16 positive cells; revision surgery patients with normal Cr concentrations did not show a significant decrease of lymphocyte subpopulations. These data suggest that the presence of metal ions, especially chromium, released from prosthesis components could be associated with changes of lymphocyte subpopulations in patients with loosening of joint prostheses.

The development and characterization of a fracture-toughened acrylic for luting total joint arthroplasties

An autopolymerizing fracture-toughened acrylic lute was developed utilizing a toughened prepolymer and a gel-polymerization method. Samples for mechanical and chemical characterization were molded from this material and from untoughened controls. Mechanical testing showed that the mode I fracture toughness (K(IC)) of the toughened lute was increased by 163% over that of the untoughened acrylic controls while the compressive strength and modulus were decreased by 36% and 34%, respectively. The flexural properties of the experimental material were not adversely affected. Analysis of molecular weight and residual monomer data for the experimental and control materials demonstrated that the increase in toughness was due to the presence of the toughened prepolymer. The use of the gel polymerization process gave excellent homogeneity with very low porosity for the experimental polymer, but it resulted in a significant increase in the residual monomer concentration due to the absence of a dispersed phase of prepolymer remnants. This raises questions concerning tissue response to the experimental system.

Development of a biocomposite to fill out articular cartilage lesions. Light, scanning and transmission electron microscopy of sheep chondrocytes cultured on a collagen I/III sponge

The regenerative capacity of hyaline articular cartilage is limited. Thus, lesions of this tissue are a proarthrotic factor, and up to now the conservative treatment of cartilage lesions and arthrosis does not yield satisfying results. Therefore, autologous transplantation of articular chondrocytes is being investigated in a variety of different assays. The aim of our study was to create a mechanically stable cell-matrix implant with viable and active chondrocytes which could serve to fill out articular lesions created in the knees of sheep. For this purpose, articular cartilage was collected from knee lesions, chondrocytes were liberated enzymatically and seeded in culture flasks and cultured till confluency. Cells were then trypsinized and grown on a type I/III collagen matrix (Chondro-Gide, Geistlich Biomaterials, Wolhusen, Switzerland) for 3, 6 and 10 days before being fixed and embedded for electron microscopy by routine methods. Scanning electron microscopy was performed after dehydration in acetone, critical point drying and sputter-coating with gold-paladium. Light microscopically, clusters of chondrocytes can be seen on the surface of the matrix with a few cells growing into the matrix. Transmission electron microscopic photographs yield a rather differentiated chondrocyte-like appearance, which is evidence of a matrix-induced redifferentiation after dedifferentiation during the growth period in the culture flasks. Scanning electron microscopic results show large, flattened chondrocytes without signs of differentiation on plastic, whereas chondrocytes grown on the Chondro-Gide sponge show a more roundish aspect wrapping firmly around the collagen fibrils, exhibiting numerous contacts with the matrix. This cell-matrix biocomposite can now serve to fill out articular cartilage lesions created in the knees of sheep.

The effect of cyclic displacement on the biomechanical characteristics of anterior cruciate ligament reconstructions

This study was conducted to clarify the influence of cyclic displacement on the structural properties of four types of femur-graft-tibia complexes used to reconstruct the anterior cruciate ligament. Forty hindlimbs from pigs were used. In two groups, bone-patellar tendon-bone grafts were secured with interference screws (group A) or the suture-post technique (group B). In two groups, multistrand flexor tendons were fixed using the tape-staple technique (group C) or the sutures-tied-over-a-button technique (group D). In each group, five femur-graft-tibia complexes underwent tensile failure tests without cyclic displacement. The other five complexes underwent 5000 cycles of cyclic elongation for 2 mm, and then underwent the tensile failure tests. The initial stiffness significantly decreased after cyclic displacement in each group, although there were no significant differences in the linear stiffness and the ultimate failure load between the tests with and without cyclic displacement. These findings suggest that 5000 cycles of repetitive elongation of the femur-graft-tibia complex by 2 mm does not jeopardize the graft fixed with the procedures used in this study, despite a slight but significant increase of an anterior-posterior laxity of the knee.

Biological performance of a three-dimensional fabric as artificial cartilage in the repair of large osteochondral defects in rabbit

A new artificial cartilage [A three-dimensional fabric (3-DF) comprising ultra-high molecular weight polyethylene fiber with a triaxial three-dimensional structure and coated with hydroxyapatite] was used to repair large osteochondral defects in rabbit knees. The knees with the 3-DF implanted in the osteochondral defects were evaluated 2-24 weeks after the operation macroscopically and microscopically. The 3-DF coated with hydroxyapatite was fixed firmly to the subchondral bone with the newly formed bone into and around the 3-DF. Hyaline-like cartilage was formed to a certain extent on the surface of the 3-DF, and the surface damage of the patella opposed to the 3-DF was minimal. In addition, the 3-DF caused no adverse effects such as particle disease, infection or severe synovitis during the experimental period. Consequently, the 3-DF seems to have successful biocompatibility in this rabbit experiment.

Changes in concentrations of biochemical markers of osteoarthritis following surgical repair of ruptured cranial cruciate ligaments in dogs

OBJECTIVE

To investigate longitudinal changes in concentrations of the 1/20/5D4 epitope (5D4) of keratan sulfate and total sulfated glycosaminoglycans (S-GAG) in synovial fluid and serum of dogs with cranial cruciate ligament (CCL) rupture that was repaired via intra-articular surgery.

ANIMALS

58 dogs with a ruptured CCL and osteoarthritis of the affected (index) joint.

PROCEDURE

Prior to surgical repair of the ruptured CCL, 5D4 concentration was measured in serum and synovial fluid samples by use of an inhibition ELISA, and total S-GAG concentration was measured in synovial fluid samples by use of a direct dye-binding assay. Ruptured CCL were repaired surgically, using an intra-articular fascial graft. Dogs were reexamined 1.5, 7, and 13 months after surgery, and 5D4 and S-GAG concentrations in synovial fluid and serum were measured again.

RESULTS

Serum 5D4 concentrations did not change significantly during the study. Concentrations of 5D4 in synovial fluid (expressed as a ratio of S-GAG concentration) did change significantly with time. In the index joint, the 5D4:S-GAG decreased from 0.19 at the beginning of the study to 0.09 1.5 months after surgery, but 7 months after surgery, the ratio increased again to 0.20.

CONCLUSIONS AND CLINICAL RELEVANCE

Results support the hypothesis that serum concentration of 5D4 is not a useful marker of osteoarthritis in dogs. Surgical intervention transiently reduced the concentration of 5D4 in synovial fluid but had no effect on S-GAG concentration.

Management of bilateral flexural deformity of the metacarpophalangeal joints in three alpaca crias

Three neonatal alpacas were treated for MCP flexural deformities. Two crias responded well to conservative therapy using splints made from fibreglass cast material. One cria with severe deformity failed to respond to conservative treatment but recovered satisfactorily after transection of the suspensory ligament in both legs. It seems that mild cases of flexural deformity of the MCP joint in alpaca crias respond well to conservative therapy but that surgical correction may be required in more severe cases. Sequential transection of the structures limiting extension of the MCP joint may result in fewer complications than previously reported techniques.

Effect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery

OBJECTIVE

To determine whether perioperative antimicrobial prophylaxis would reduce incidence of postoperative infection among dogs undergoing elective orthopedic procedures.

DESIGN

Randomized, controlled, blinded, intention clinical trial.

ANIMALS

Dogs of any breed, sex, or age undergoing elective orthopedic surgery at a veterinary teaching hospital.

PROCEDURES

Dogs were randomly assigned to 1 of 3 groups: treatment with saline solution, treatment with potassium penicillin G, and treatment with cefazolin. Treatments were intended to be administered within 30 minutes prior to surgery; a second dose was administered if surgery lasted > 90 minutes. Dogs were monitored for 10 to 14 days after surgery for evidence of infection.

RESULTS

After the first 112 dogs were enrolled in the study, it was found that infection rate for control dogs (5/32 dogs) was significantly higher than the rate for dogs treated with antimicrobials (3/80 dogs). Therefore, no more dogs were enrolled in the study. A total of 126 dogs completed the study. Monte Carlo simulations indicated that compared with dogs that received antimicrobials prophylactically, dogs that received saline solution developed infections significantly more frequently. Difference in efficacy, however, was not observed between the 2 antimicrobial drugs used.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that perioperative antimicrobial prophylaxis decreased postoperative infection rate in dogs undergoing elective orthopedic surgery, compared with infection rate in control dogs. Cefazolin was not more efficacious than potassium penicillin G in these dogs.

Arthroscopic subchondral bone plate microfracture technique augments healing of large chondral defects in the radial carpal bone and medial femoral condyle of horses

OBJECTIVE

To evaluate the effect of arthroscopic subchondral bone microfracture on healing of large chondral defects in horses.

STUDY DESIGN

Short- (4 months) and long-term (12 months) in vivo experimental chondral defect model.

ANIMALS

10 horses, aged 2 to 5 years.

METHODS

Each horse had a 1 cm2 full-thickness chondral defect created in both radial carpal bones and both medial femoral condyles. One carpus and one femoral condyle of each horse had the subchondral bone plate under the defect perforated using an orthopedic awl. All horses were exercised, five horses were evaluated after 4 months and five horses after 12 months. Gross, histologic, and histomorphometric examination of defect sites and repair tissues was performed, as was collagen typing of the repair tissue.

RESULTS

On gross observation a greater volume of repair tissue filled treated defects (74%) compared with control defects (45%). Histomorphometry confirmed more repair tissue filling treated defects, but no difference in the relative amounts of different tissue types was observed. There was an increased percentage of type II collagen in treated defects compared with control defects and evidence of earlier bone remodeling as documented by changes in porosity.

CONCLUSIONS

In full-thickness chondral defects in exercised horses, treatment with subchondral bone microfracture increased the tissue volume in the defects and the percentage of type II collagen in the tissue filling the defects when compared to nontreated defects.

CLINICAL RELEVANCE

No negative effects of the microfracture technique were observed and some of the beneficial effects are the basis for recommending its use in patients cases with exposed subchondral bone.

[Cost analysis of autologous transfusion methods--a study of 5,017 patients]

PURPOSE

Cost analysis of autologous blood conservation measures compared to corresponding homologous blood products.

METHODS

This study is based on data from 5,017 patients undergoing major bone and joint surgery in 1993 and participating preoperatively in autologous blood donation (ABD) (with hemoseparation (HS) into autologous packed red blood cells (APRBC) and autologous fresh-frozen-plasma (AFFP)), autologous plasmapheresis (APPH) for harvesting AFFP as well as intra-/postoperative blood salvage with mechanically processed autologous transfusion (MAT).

RESULTS

Total costs for 3,110 ABD with HS amount to DM 517,586.00 resulting in about DM 167.00 per U of APRBC plus AFFP. Comparatively, costs per U of HPRBC is about DM 202.00. Break-even-point (BEP) is calculated with 2,258 U of APRBC (without considering AFFP additionally obtained by HS). Taking into account this AFFP due to coagulation in 20% lowers BEP to 1,819 U of APRBC. However, this analysis compares the "mere" cost figures only, but does not consider the extent of ABD-induced increase in rbc mass compared to that of HPRBC. Under these circumstances calculated cost per unit of APRBC is up to 90 per cent higher than for 1 U of HPRBC. Total cost for PPH with 15,570 U of AFFP amounts to about DM 1,824,162.00, resulting in about DM 115.00 per U of AFFP. Comparatively, cost per U of HFFP is about DM 136.00. BEP is calculated with 11,595 U of AFFP. However, when considering AFFP on coagulatory reasons' with 20% only, no BEP can be calculated and AFFP is not proven to be cost-efficient. Under these conditions it is about 2.8-times more expensive than HFFP; and if considering AFFP a volume substitute it is even more than twelve times more expensive than artificial colloids (e.g. HES 6%, 200/0.5). MAT--2,690 sets and patients with a total of 5,326 processing cycles--causes a total cost of about DM 1,356,161.00, resulting in about DM 504.00 per set and patient. Under our conditions MAT is not cost-efficient compared to HPRBC as it is about two times more expensive than HPRBC. For reaching cost efficiency the number of processing cycles is either to be increased from about 2 to about 4 cycles per set and patient or hematocrit of the rbc-product obtained by MAT is clearly to be increased.

CONCLUSIONS

The "mere" figures of this cost analysis of APRBC versus HPRBC as well as of AFFP versus HFFP and HES appear in favour of the autologous products. However, such an analysis should consider--besides the costs--both the increase in rbc-mass obtained by ABD or MAT, versus homologous rbc, and the indication for administering AFFP. This study does not prove our autologous blood conservation measures to be cost efficient compared to homologous blood products. Therefore, these data may cause a critically reflection on established concepts of autologous transfusion measures and may initiate promoting new and more cost efficient constellations/alternatives of blood conservation measures.

Arthroplasty after war injuries to major joints

From 1992 to 1995, replacement of the joint with an endoprosthesis after serious wounding and major destruction of joint elements was performed in 10 soldiers. Arthroplasty was performed on five knees, three hips, and two shoulders. The age range of the wounded soldiers was 22 to 55 years (mean, 37.7 years). Six soldiers suffered explosive injuries, and 4 were injured by gunfire. Time elapsed from the moment of wounding to the time of total joint replacement was 9 to 42 months. We decided on arthroplasty as the preferred treatment because of the presence of strong contractures and very painful movement. In 8 patients, the results of the treatment, based on a follow-up time of 36 to 48 months, were good. In 2 patients, early septic arthritis developed after arthroplasty of the knee with concomitant loosening of the endoprosthesis. Staphylococcus aureus was detected in both patients. In those 2 patients, therefore, arthrodesis of the knee with external fixation was performed.

Determining surgical priorities in rheumatoid arthritis

Rheumatoid arthritis often affects multiple joints simultaneously with pain, deformity and loss of function. The indications for surgical treatment are presented along with guidelines for determining the surgical priorities along with guidelines for determining the surgical priorities when multiple joints require surgery.

[Effect of diclofenac on human osteoblasts and their stromal precursors in vitro in relation to arthroplasty]

INTRODUCTION

Results of animal experiments have demonstrated that the osseous integration of non-cemented prostheses can, at the very least temporarily, be impaired by the application of non-steroidal antiphlogistic agents (such as diclofenac). It is the objective of this study to examine whether there is a direct influence of diclofenac used in usual clinical dosages (3 times 50 mg daily) on bone cells and their progenitor cells which would explain the observed slow integration of the prostheses.

METHODS

To investigate this, cultivated human in vitro osteoblasts and stromal bone marrow cells were incubated with increasing doses of the medications. Our study focused on the effect of diclofenac application on proliferation and functional metabolism in both cell lines. The measurable maximal plasma concentration 2 h after the application of one tablet Voltaren 50 reached 1.6 micrograms/ml. This correlated with diclofenac concentrations between 1 and 10 ml found in our experiments. The detected values were correlated to the control group (0 microgram/ml diclofenac).

RESULTS

The drug effect upon osteoblasts was higher than on progenitor cells. The proliferation of in vitro stromal bone marrow cells, compared to untreated cells, was found to be decreased. We observed a decrease to 82% at a diclofenac concentration of 1 microgram/ml, Osteoblasts exhibited a decrease to 97.5% at the same concentration. The DNA synthesis increased to 118% in stromal bone marrow cells, in osteoblasts to 144%. In contrast, we detected a neglectible decrease to 92% in the collagen synthesis of osteoblasts compared to untreated cells. The synthesis of osteocalcin by osteoblasts increased to 119%. The alkaline phosphatase activity was found to be decreased to 88% in stromal bone marrow cells and increased in osteoblasts to 111%.

CONCLUSION

Temporary inhibiting effects on osseous integration in non-cemented prosthesis by diclofenac could be caused by a disturbance in the anabolic bone metabolism, exhibited by an increase of osteoblastic osteocalcin expression. Osteocalcin as a known negative regulator of the osteoneogenesis is most likely inhibiting the collagen matrix deposition.

Treatment of intraarticular fractures with modified herbert screws (analysis of 69 cases)

Sixty-nine patients with intraarticular fractures were treated with modified Herbert screws between August 1988 and December 1994. They were followed for an average of 20 months (range, 6 months to 4 years). The final results were assessed in terms of patient satisfaction, clinical examination, and radiographic findings. The success rate was 89.8% (62/69). There were no serious complications. The authors believe the advantages of the modified Herbert screw over the Arbeitsgemeinschaft für osteosynthesefrogen cancellous bone screw are many. The modified Herbert screw provides rigid internal fixation with strong purchase on the bone, so that additional immobilization in plaster is seldom required. It can be inserted through articular cartilage and appropriately buried beneath the articular surface. It is not necessary to remove the screw after bone union. This type of fixation can be widely used in the clinical setting.

[Autologous osteochondral transplantation on various joints]

A chondral/osteochondral defect involving the articular surface of a joint is still a therapeutic problem. The goal of articular cartilage repair is restoration of cartilage congruity, accomplishing full painfree range of motion and elimination of cartilage detoriation. The use of autologous grafts was first reported by Wagner 1964. Now the use of cylindrical autograft plugs was described by Bobic 1996 and Hangody 1996. Operative management and early results of osteochondral cylindrical autograft plugs in the femoral condyle, patella, elbow and talar dome are presented. The arthroscopic/open use of autologous osteochondral grafts from the knee is indicated in osteochondral lesions in diameter from 1 to 3 cm, which can not be primarily refixed and in osteonecrosis at femoral condyle, patella, elbow, talar dome as well as shoulder.

[Autologous osteo-chondral grafts in the management of articular cartilage lesions]

It is well known that the capacity of articular cartilage for repair is limited. There have been many attempts to address this problem. However, treatment options are limited and the long-term outcome is uncertain. This article will focus on the osteochondral autograft transplantation (OAT), which is currently the only surgical cartilage repair technique that provides and retains proper hyaline articular cartilage. Osteochondral autograft transplants have been associated with a good rate of success, but further long-term follow-up and biomechanical evaluation are essential.

LIMITATIONS

size and depth of osteochondral defects, availability of donor autologous grafts, potential for damaging donor sites, the dead spaces between circular grafts and integration of donor and recipient hyaline cartilage.

Radiographic evaluation of elbow joints before and after surgery in dogs with possible fragmented medial coronoid process

OBJECTIVE

To determine the usefulness of 5 radiographic projections of the elbow joint for identification of fragmented coronoid process (FCP) and associated secondary degenerative changes in dogs.

DESIGN

Longitudinal clinical study.

ANIMALS

19 dogs suspected of having FCP (7 dogs, 1 elbow joint; 12 dogs, both elbow joints).

PROCEDURE

5 radiographic projections were obtained before and after surgery for all elbow joints on which exploratory arthrotomy was performed because of suspected FCP. Radiographs obtained before surgery were compared with radiographs obtained after surgery and radiographs taken of the excised fragments. Each projection was evalated for its utility in definitively identifying FCP and 7 specific degenerative changes. Interevaluator agreement, use of each radiographic projection for definitively identifying a feature, and ability of the 4 evaluators to definitively identify a feature were analyzed.

RESULTS

The craniolateral-caudomedial oblique (Cr15L-CdMO) projection had a significantly higher sensitivity for definitively identifying FCP, compared with the other 4 projections. Interevaluator and kappa agreement for the 5 projections did not differ significantly among the 7 degenerative changes evaluated. The radiographic projection with the highest sensitivity and specificity for detection of a particular degenerative change varied by feature.

CLINICAL IMPLICATIONS

Of the 5 radiographic projections evaluated, the Cr15L-CdMO projection provided the highest sensitivity and was the best projection to use for definitively identifying FCP. The craniocaudal, Cr15L-CdMO, and mediolateral projections most reliably allowed for identification of secondary degenerative changes.

[The floating joint injury of the lower and upper extremity--epidemiology, therapy and results in 40 extremities]

GOAL

Floating Joint Injuries (FJI) are resulting from high energy traumas and are often combined with additional neuro/vascular damage. The high incidence of severe open or closed soft tissue injuries is complicating the initial management and requires a broad surgical know-how also in minimal-invasive fixation techniques. In a retrospective analysis of our cases treated between 1980 and 1995, we try to find out some important therapeutical feedback for the future.

MATERIAL AND METHODS

Of the 37 patients, 33 had a FJI of the lower (2 bilateral) and 7 patients of the upper extremity. 90% were road traffic injuries, 75% showed an open fracture situation and 25% an associated neuro-vascular injury. All fractures were stabilised within the first hours, femur, humerus and forearm in one step, the tibia in 33% in two steps (initial external fixator ...). 80% of the FJI have been reexamined after 1-2 y.

RESULTS

Local complication: Femur: 4/33 (1 infection, 2 refractures, 1 non-union). Tibia: 11/33 (5 infections, 4 delayed/non-unions, 2 malalignements). Humerus: 0/7. Forearm: 1/7 (1 malalignement). 1-2 y-results: Very good-good: Femur: 26/27 (96%). Tibia: 23/27 (85%). Humerus: 4/5. Forearm: 3/5.

DISCUSSION

FJI should be stabilised as soon as possible in a way allowing for early functional aftercare of the affected joint. Most complications are observed in the proximal tibia fracture because of the thin and therefore often severely (open or closed) injured soft tissue cover. Despite a staged procedure, there exists a high complication rate, which probably can be reduced in the future by the single-step use of the hybrid external fixateur.