A guide instrument for high tibial osteotomy

Fifty-two patients (52 knees) with medial gonarthrosis were subjected to high tibial osteotomy using the Tjörnstrand guide instrument. The intended wedge was calculated from a whole lower limb radiograph. The correction aimed at was an overcorrection of 4 degrees in valgus of the hip-knee-ankle angle. All but 1 case were corrected to +/- 3 degrees of the intended angle. All but two cases healed within +/- 3 degrees of the achieved surgical correction, i.e., a substantial improvement compared with our previous freehand technique where one fifth were outside this interval. We conclude that in knee surgery a guide is as important for osteotomies as for arthroplasties.

Analgesic efficacy and safety comparison of ketorolac tromethamine and Doleron for the alleviation of orthopaedic post-operative pain

The analgesic efficacy and safety of ketorolac tromethamine (ketorolac), a potent analgesic with anti-inflammatory and antipyretic activities, were evaluated and compared with Doleron, a combination analgesic, in 115 patients with moderate to severe orthopaedic post-operative pain. This was a randomized, double-blind (double-dummy), parallel-group comparison of a single oral dose of one capsule of 10 mg ketorolac with a single oral dose of two Doleron tablets (each tablet contained 150 mg dextropropoxyphene napsylate, 350 mg aspirin and 150 mg phenazone). During the 6 h following treatment, 80% of ketorolac treated patients and 82% of Doleron treated patients experienced adequate pain relief. There were no statistically significant differences in the overall analgesic efficacy between the treatment groups. Three patients (one on ketorolac, two on Doleron) withdrew because of adverse events (vomiting). Nausea (two patients in each treatment group), vertigo (none on ketorolac, three on Doleron) and sore throat (none on ketorolac, two on Doleron) were the only drug-related adverse events reported by more than one person in a treatment group during the trial. A total of 82% of patients given ketorolac and 76% given Doleron experienced no adverse events. A single oral dose of 10 mg ketorolac was shown to be as effective and safe as two Doleron tablets in the treatment of moderate to severe orthopaedic post-operative pain.

A stabilometric technique for evaluation of lower limb instabilities

Stabilometry is a technique designed to register postural equilibrium control. This investigation used a computerized strain gauge force plate to measure sway movements in the frontal plane with the patient standing on one leg. Fifty-five young healthy individuals were studied as a reference group and to determine the reproducibility of the method. The clinical population consisted of 14 patients with unilateral injuries to the lateral ligaments of the ankle. These were measured, both with and without an ankle brace. The different parameters used to describe the body sway could well discriminate between the injured and the uninjured leg. When the brace was used the effect was obvious and none of the parameters showed any significant difference compared to the uninjured leg.

The PCA unicompartmental knee. A 1-4-year comparison of fixation with or without cement

Totally, 93 knees were operated on with the PCA unicompartmental knee for gonarthrosis Stages I-III according to Ahlbäck. The clinical findings for 84 arthroplasties with 1-4 years' follow-up showed 82 excellent or good results. The mean postoperative flexion was 124 degrees. The position of the tibial component was respectively 86 degrees and 89 degrees in the AP and lateral views. The mechanical axis was slightly undercorrected. There were two failures, both with persistent pain on walking. One failure was among 43 uncemented knees, whereas the other was among the 41 cemented arthroplasties. Four uncemented arthroplasties had a first steps' problem but were satisfactory otherwise. There was no infection or clinical loosening. A reoperation was performed in 1 case, in which a symptomatic osteophyte was removed. When compared with our earlier Marmor series, the PCA unicompartmental arthroplasties were better. The cemented arthroplasties had a somewhat higher frequency of complete pain relief. An uncemented arthroplasty should only be considered in special situations.

Micromotion of noncemented Freeman-Samuelson knee prostheses in gonarthrosis. A roentgen-stereophotogrammetric analysis of eight successful cases

Micromotion of the tibial component of eight Freeman-Samuelson arthroplasties without cement for gonarthrosis were followed for two years and studied by roentgen-stereophotogrammetric analysis (RSA). In five cases, displacement over time was studied, and in all cases migration was found to range from 0.7 to 4.8 mm after two years. One tibial component migrated continuously during the period studied, while the remaining prostheses migrated mostly during the first six months. The direction of the migration was erratic. Inducible displacement ranging from 0.8 to 5.0 mm was found in all cases. Clinically, all of the patients were scored as successful although one with continuous migration had the lowest score. This degree of micromotion is compatible with good results after two years, and appears to be a characteristic of the immediate interlocking fixation used in the Freeman-Samuelson prosthesis.

Micromotion of conventionally cemented all-polyethylene tibial components in total knee replacements. A roentgen stereophotogrammetric analysis of migration and inducible displacement

Micromotion of the tibial component in 27 knee arthroplasties for gonarthrosis, three of which were regarded as failures for reasons other than mechanical loosening, was studied using high-resolution roentgen stereophotogrammetric analysis (RSA). Migration over time was found in all cases, ranging from 0.2 to 2.1 mm. The majority of the cases showed migration during the first year only, while a minority migrated continuously during the period studied. The latter group showed more migration even after 1 year. All cases showed inducible displacement in response to external forces, ranging from 0.2 to 1.0 mm. The micromotion correlated with the age of the patient but not with other demographic parameters. Alignment or component position did not correlate with the micromotion. All cases but one had developed a radiolucent zone, and it was concluded that the micromotion occurred in the soft tissue interface between bone and cement. Such micromotion is a normal finding in cemented tibial components in knee arthroplasty.

Tibial component fixation in knee arthroplasty

Using roentgen stereophotogrammetric analysis (RSA), the integrity of the bond between the tibial component and the tibia was studied in seven knees, implanted with a cemented Kinematic total knee prosthesis for gonarthrosis. Migration ranging from 0.3 to 1.9 mm over a two-year period occurred in all seven cases. Displacement, induced by external forces, ranging from 0.2 to 1.0 mm was observed in five cases. Measurable migration and inducible displacement may be the rule rather than an exception in total knee arthroplasty (TKA). Accordingly, absolute rigid fixation would not be necessary for successful function of a TKA.

Survival of knee arthroplasties. A nation-wide multicentre investigation of 8000 cases

A prospective nation-wide study of knee arthroplasty has been under way in Sweden since October 1975. By the end of 1983, 4505 arthroplasties for osteoarthritis and 3495 for rheumatoid arthritis had been recorded and reviewed one, three and six years after the operation. Using actuarial methods, the probability of the prosthesis remaining in situ after six years was calculated. In osteoarthritis this probability ranged from 65% for hinged prostheses to 90% for medial compartment prostheses. Two-and three-compartment prostheses produced intermediate results with 87% survival. In rheumatoid arthritis the probability varied from 72% for medial compartment prostheses to 90% for two- and three-compartment prostheses. The main reason for failure was loosening of the components, the second most common was infection. The probability of revision for infection by six years was 2% in osteoarthritis and 3% in rheumatoid arthritis. Most revisions were to a three-compartment prosthesis. Knee fusion at primary revision was required in 2% of the cases at six years.

Arthrodesis for failed knee arthroplasty. A report of 20 cases

Twenty consecutive patients treated by arthrodesis for failed knee arthroplasty are reviewed. Eight hinged, five stabilised and seven compartmental prostheses were removed, for infection (15 cases), loosening (4) and instability (1). One patient refused a second-stage operation but the remainder gained sound fusion. Infected knees had a two-stage procedure with temporary insertion of gentamicin-loaded beads after removal of the prosthesis; all infections healed. Six arthrodeses using a Hoffmann-Vidal external fixator resulted in two temporary failures. One Ace-Fischer external fixation was successful. Of 10 primary attempts at arthrodesis with an intramedullary Küntscher nail, nine were successful; the tenth fused after two more attempts by the same method. The two failures of external fixation and two failures after Charnley single-frame compression done elsewhere were successfully fused with intramedullary nails. Delayed union in three cases fused after prolonged fixation and repeated bone grafts. The indications for and methods of arthrodesis after failed knee arthroplasty are discussed.

Arthrodesis after failed knee arthroplasty. A nationwide multicenter investigation of 91 cases

Ninety-one patients with attempted arthrodesis after failed knee arthroplasty were identified in a prospective nationwide study of knee arthroplasties performed from October 1975 through January 1982 in Sweden. The study included 43 hinged or stabilized, 34 bi- or tricompartment, and 14 unicompartment endoprostheses. Three-fourths of the failures were caused by infections. At follow-up evaluation, two patients had expired from infection and four patients had amputations. Fusion was achieved in only 50% of 108 attempts in 91 knees. Patients with unstable joints had limited function. The fusion rate was relatively high after unicompartment endoprostheses, in cases with sustained rigid fixation, or in cases where infection was brought under control at arthrodesis. Rigid fixation was best achieved with an external double frame or an intramedullary nail. Repeated attempts were worthwhile. Removal of all foreign material, eradication of the infectious lesion, and an arthrodesis performed in a one- or two-stage procedure with insertion of gentamicin beads seemed to be the best way to combat infection. The treatment of prosthetic failures should be referred to centers with special interest in knee arthroplasty.

Migration of the tibial component in successful unicompartmental knee arthroplasty. A clinical, radiographic and roentgen stereophotogrammetric study

Migration of the tibial component in unicompartmental Marmor knee arthroplasty was measured by conventional radiography and roentgen stereophotogrammetry during a 2-year follow-up of six patients operated on for femoro-tibial arthrosis. The clinical course was satisfactory for all six patients. A radiolucent zone developed in all cases, the width of which was greater than 2 mm in one case. By radiography movements of two of the six prosthetic components could be detected. Roentgen stereophotogrammetry showed significant rotational and translatory movements in all six tibial components. In four cases these movements were small not exceeding 1 mm for translation and 1.5 degrees for rotation. The remaining two components showed larger migrations with maximum values of 2.7 mm for translation and 12.6 degrees for rotation. Five of the components tilted backwards about the transverse axis, four tilted away from the centre of the knee about the sagittal axis, and four rotated with the anterior part away from the centre of the knee about the vertical axis. The small movements of the four tibial components may be due to a semi-rigid fixation by connective tissue in the bone-cement interface. Since all knees were asymptomatic, neither the zones nor the minor movements seemed to have any clinical significance within the follow-up period.

Injuries sustained in junior league handball. A prospective study of validity in the registration of sports injuries

In a study of injuries sustained in junior league handball, all injuries during 685 hours of play sustained by 7 320 players have been registered in a cup tournament. Junior handball appears generally to have a very low injury risk, but with a clearly indicated tendency towards more injuries in the higher age group and fewer injuries in the lower age group and among girls. The more serious injuries sustained during a junior handball tournament are carefully registered by the tournament doctor, but the less serious injuries must, if so wished, be registered by other means, for example by telephone call or postal report after the tournament games.

Use of a guide instrument for compartmental knee arthroplasty

To improve the positioning of the tibial component in compartmental knee arthroplasty a guide instrument was introduced. With the guide instrument the position in the frontal plane significantly improved from a mean medial slope of 10 degrees to 2 degrees. In the sagittal plane the change from a mean posterior slope of 5 degrees to 3 degrees was insignificant. The mean value for the Hip-Knee-Ankle angle (HKA) (ideal 180 degrees) was 186 degrees after "free-hand" operation and 183 degrees with the modified operative technique. Thus, it is possible with the aid of a guide instrument to improve the precision in compartmental knee arthroplasty.

The Lund drill guide. An instrument for repair or reconstruction of the cruciate ligaments

A new drill for cruciate ligament repair is described. It is a modification of a French drill guide (Landanger). The guide allows for the possibilities of free adjustment in all planes and good stability during the drilling procedure. The instrument has been used in 22 patients with anterior cruciate ligament injuries and five patients with injuries to the posterior cruciate ligament. With this instrument it is sufficient with only an anterior approach for a posterior cruciate ligament repair. It is concluded that the Lund cruciate drill guide is simple and manoeuvrable for surgery of the ligaments of the knee joint. In all cases correct drilling was possible and in no instance the instrument has failed.

Tibial osteotomy in medial gonarthrosis. The importance of over-correction of varus deformity

In a prospective series of 52 knees selected for high tibial osteotomy because of early medial arthrosis, special care was taken to obtain a final over-correction in valgus. The operative procedure and the pre- and post-operative radiographic examinations were standardized and the follow up was 1-3 years. 49 of the 52 knees had obtained a normal or over-corrected mechanical axis. 45 of these had improved painfree walking distance, and 31 were painfree. In 45 knees the arthrotic condition had not progressed, and in 5 of these there were signs of cartilage restitution. It is concluded that precise correction of medial gonarthrosis can be achieved, and this provides a rational basis for definitive treatment of early stages of this condition: for the majority an endoprosthesis operation should not be needed in the future.

Roentgen stereophotogrammetry in high tibial osteotomy for gonarthrosis

In three cases operated with high tibial osteotomy for medial gonarthrosis the exact method of roentgen stereophotogrammetry with tantalum balls as bone markers (Selvik 1974) was used to study angular and translational movement in three dimensions at the operation and during the healing period. Tibial osteotomy caused angular and translational movements even in planes where correction was not intended, and the stereo technique revealed that stability was not present when knee mobilisation started. Correlation between the stereo values and conventional radiographic measurements were best in the frontal plane (root mean square value of discrepancies 1.3 degrees). Roentgen stereophotogrammetry gives superior information compared with the conventional radiographic technique, but it is concluded that the latter has sufficient accuracy for the clinical assessment of corrections in the frontal plane.

Talofibular compartment of the ankle joint after recent ankle sprain

The validity of predicting the condition of the anterior talofibular ligament from the shape of the lateral compartment of the ankle joint was investigated in patients with recent ankle sprain. The diagnostic value of the method was found to be restricted.