PHLEBOGRAPHY IN OSTEOARTHRITIS OF THE HIP

Long-term results after Colonna's operation

A long-term review of 82 patients (117 hips) who had Colonna's operation for congenital dislocation of the hip has been carried out. Although early assessments had shown a high proportion of good results these deteriorated with time. At our latest review of 61 hips, with an average follow-up of 30 years, 34% had moderate, and 66% severe, osteoarthrosis; many of these patients now need a total hip replacement. We conclude that Colonna's operation is only indicated in a small number of cases. It should never be carried out over the age of 6 years, and only in younger children when there is severe underdevelopment of the acetabulum or where procedures which preserve the articular cartilage are unlikely to be successful.

Intra-operative collapse or death related to the use of acrylic cement in hip surgery

Six intra-operative deaths and two episodes of near-fatal hypotension occurred in 52 consecutive Hastings procedures (insertion of metal prosthesis grouted in acrylic cement) for subcapital fracture of the femoral neck. This high complication rate was identified by a system of clinical audit undertaken by members of the anaesthetic department.

Intraosseous pressures of oxygen and carbon dioxide in coxarthrosis

We have investigated the intraosseous partial pressures in 15 patients suffering from primary arthrosis of the hip. The measurements were performed by a mass spectrometer via a specially designed inlet system. The average pO2 and pCO2 values in the femoral head were 8.2 and 6.8 kPa (62 and 52 mmHg), respectively, and in the greater trochanter 6.6 and 5.1 kPa (51 and 39 mmHg). The average intraosseous pressures in the femoral head and greater trochanter were 5.5 and 3.0 kPa (42 and 23 mmHg). The differences between the intraosseous pressures, pO2 and pCO2 in the greater trochanter and the femoral head were all significant.

Medial and lateral gonarthrosis treated with high tibial osteotomy. A prospective study

A prospective series comprising 52 knees in 48 patients suffering from medial or lateral unicompartmental gonarthrosis and treated by means of high tibial osteotomy shows, by comparing mechanical axis (MA) 0 degrees corrected knees, how important is the overcorrection of the MA into valgus in medial osteoarthritis. The clinical results were significantly correlated to overcorrection, the results 2 years postoperatively being better than those obtained at a follow-up 1 year after the operation. Of the results, 82% were good within a limit of +/- 3 degrees after 2 years, while only 77% were correspondingly good 1 year postoperatively. In lateral gonarthrosis overcorrection was not as good, but there was a mean overcorrection of +2 degrees, and with respect to this overcorrection, the results were quite acceptable. The results were directly correlated to the opening up of the joint space affected (80%) and diminution or disappearance of subluxation, 1/3 being 0 degrees preoperatively, 1/2 postoperatively in medial gonarthrosis. In lateral gonarthrosis, subluxation was increased, with 2/3 being 0 degrees preoperatively, 1/3 being 0 degrees postoperatively. The extension deficit in varus knees significantly diminished after valgus osteotomy; the change in valgus knees was also evident but not significant. The mean value of extension deficit was below 5 degrees in all cases at the 2 years' follow-up examination. However, 95% of all patients showed good or fair results after a follow-up period of 2 years.

Arthroscopic surgery for relief of pain in the osteoarthritic knee

This retrospective study reviews 43 patients with osteoarthritis of the knee who underwent arthroscopic surgery, from January 1979 until April 1982. Percutaneous drilling of an osteochondral defect in the femoral condyle was performed in 22 patients to relieve the high intraosseous pressure and rest pain associated with this disease; successful results were recorded in 80% of patients at an average followup of 25.1 months. Partial meniscectomy was performed in 21 patients to remove an obstructing degenerative meniscal tear; 81% had successful results with an average followup of 40.6 months. There were no postoperative complications. Percutaneous drilling and excision of degenerative meniscal tears can be valuable arthroscopic procedures in properly selected patients with osteoarthritis of the knee.

Pain and internal hypertension in bone lesions

Internal pressures of bone tumors and tumorous conditions were measured in 20 patients. High pressures were frequently found in patients with painful bone lesions while low pressures were common in patients with no pain. Internal hypertension may be a causative factor of aching bone pain at rest.

The relationship between increasing intraarticular pressures and intraosseous pressures in the juxtaarticular bones. An experimental investigation in dogs

The present experiment investigation of the relationship between intraarticular and intraosseous pressures was carried out in mongrel dogs. Under general anaesthesia simultaneous pressure measurements were performed in the femoral artery, the knee joint and the tibia and femur adjacent to the knee joint. The intraarticular pressure was increased by infusion of saline. Increase in the knee joint pressure caused an increase in the femoral intraosseous pressure, while the tibial intraosseous pressure remained unchanged. The pressure increase in the femur was most pronounced in dogs with intact epiphyseal plates. It is suggested that the rise in the femoral pressure was caused by compression of the venous drainage from the bone. Further evidence to support this suggestion was obtained from anatomical studies, intraosseous phlebography and experiments with selective venous compression.

Primary osteoarthritis of the hip. Interrelationship between intraosseous pressure, X-ray changes, clinical severity and bone density

The intraosseous pressure of the femoral head and greater trochanter was measured during 146 Charnley hip replacement operations. In 108 hips with primary osteoarthritis the pressure in the femoral head averaged 49.6 and in the greater trochanter 31.6 mmHg. The pressures in the greater trochanter were significantly lower than those in the femoral head. There was no sex difference, and the pressures were independent of age. The intraosseous pressure in the femoral head varied appreciably with a dispersion which did not significantly differ from the normal distribution. There was a faintly positive correlation between the mean blood pressure and the intraosseous pressure. No relationship was found between the pressure in the femoral head and the radiological severity of the osteoarthritis or between the intraosseous pressure and the duration of symptoms, severity of rest pain, walking ability, range of motion or degree of bone density at the site of measurement. The haemodynamic conditions in bone depend upon blood flow and resistance. Variations in these two factors determine the actual intraosseous pressure. As a consequence intraosseous pressure measurement as the only evaluation of the haemodynamic conditions is of limited value. The vascular factor in osteoarthritis needs further clarification.

Intraosseous phlebography, intraosseous pressure measurements and 99mTC-polyphosphate scintigraphy in patients with various painful conditions in the hip and knee

Twenty-five patients with pain in the knee or hip were examined by means of bilateral intraosseous phlebography, intraosseous pressure measurements and 99mTechnetium polyphosphate scintigraphy. All patients with typical rest pain--either due to osteoarthritis or to the intraosseous engorgement-pain syndrome--showed venous stasis and increased pressure in the bone marrow near the painful joint and abnormally high uptake of the radiotracer. In patients with other types of pain this correlation was absent. The results indicate that 99mTechnetium polyphosphate scintigraphy can be used as a screening method in the diagnosis of the intraosseous engorgement-pain syndrome in patients with a typical history. However, increased isotope uptake in a joint region may be due to a variety of other causes. The identical findings with all three methods of investigation in patients with the intraosseous engorgement-pain syndrome and osteoarthritis suggest a common pathomechanism.

Osteotomy of the patella in chondromalacia. Preliminary report

There are many factors involved in the aetiology of chondromalacia of the patella. If possible, the appropriate operative procedure should be chosen for each patient, hence attempting to eliminate the cause of softening of the cartilage. Increased pressure over the lateral facet, with or without reduced pressure over the medial facet of the patella, resulting from lateral positioning or tilting of the patella, the Wiberg/Baumgartl-types III and IV, and the "Hunter's Hat" form are important causes. With reduced pressure, the cartilage is inadequately stressed and consequently receives insufficient nourishment. As the medial facet is particularly thick and has little contact with the femoral condyle, nutritional disturbance is almost a normal occurrence. Longitudinal osteotomy of the patella has been found to improve the contact of the medial surface of the patella with the femoral condylar groove. The analgesic effect of this surgical procedure may derive from the resultant reduction in subchondral interstitial pressure, presuming that the pain in chondromalacia patellae, like that of osteoarthritis, is a manifestation of raised intramedullary pressure. To ensure an improvement in patellar tracking the osteotomy is combined with a lateral capsular release.

The effect of fenestration on intraosseous drainage in osteoarthritis of the hip

Eight patients with osteoarthritis of the hip, rest pain and intraosseous hypertension of the proximal femur obtained ameliorated rest pain and reduced intraosseous hypertension 3 months after a fenestration operation in the region of the greater trochanter. They were investigated with intraosseous phlebography of the proximal femur. Six patients showed delayed intraosseous drainage and 7 had altered patterns of drainage before the operation. Three months after the operation the phlebograms showed an even more prolonged drainage time. However, this difference was not of a statistically significant magnitude. Drainage patterns remained mainly unchanged.

Experimental osteoarthritis in the rabbit knee joint

The development of arthrotic-like changes following the resection of the cruciate ligaments in the knee joint of rabbits has been studied at intervals from 2 weeks to 10 months in 35 animals. Signs of cartilage degeneration were followed by changes in the subchondral bone, where formation of osteophytes and condensation took place. An increased vascular supply was demonstrated by microangiographic and scintigraphic investigations. The uptake of 18F and 99mTc-polyphosphate reached a maximal value about 2 months after the operation and then diminished despite further development of arthrotic changes.

Intraosseous pressure in the femoral head and greater trochanter before and 1-3 years after osteotomy for osteoarthritis of the hip joint

To elucidate the long-term effect of osteotomy upon the intraosseous pressure in osteoarthritis of the hip, pressure measurements in the femoral head and greater trochanter were performed in 22 patients before intertrochanteric osteotomy and 11.5-33.5 months later, on the occasion of removing the osteosynthesis material after the osteotomy had healed. Preoperatively the mean pressure in the femoral head was higher (35.0 mmHg) than in the greater trochanter (23.4 mmHg). At follow-up the mean pressure in the femoral head had fallen, but not significantly (0.10 less than P less than 0.20). A significant reduction in pressure (0.001 less than P less than 0.005) was found in 10 patients in whom the primary pressure was high (exceeding 35 mmHg) and in 16 patients seen at follow-up less than two years after the osteotomy (0.01 less than P less than 0.02), whereas with a longer observation period there was a tendency towards an increasing pressure. The trochanteric pressures accompanied the pressures in the femoral head, but without significant changes. No close correlation was found between intraosseous pressure and pain at rest. The operation had a good clinical effect, especially upon the pain at rest. A reduction in intraosseous hypertension may be a contributory cause, but the tendency to another increase in pressure after a long observation period indicates the possibility of a subsequent recurrence.

Peroperative effect of fenestration upon intraosseous pressure in patients with osteoarthritis of the hip

In nine patients with osteoarthritis of the hip who suffered from pain at rest, intraosseous pressure was measured in both the femoral head and neck before and immediately after fenestration in the lateral aspect of the greater trochanter. A small but significant drop in intraosseous pressure in both the femoral neck and head was registered as a result of the fenestration procedure.