Abnormalities of somatosensory perception in patients with painful osteoarthritis normalize following successful treatment

To investigate the effect of chronic nociceptive pain on somatosensory perception, quantitative sensibility testing was performed in the most painful area and the homologous contralateral side in 14 patients with painful osteoarthritis of the hip. Twelve patients were reassessed in a painfree state 6-14 months following surgery. Von Frey filaments were used to test low-threshold mechanoreceptive function. Pressure pain sensitivity was assessed with a pressure algometer and thermal sensitivity with a Thermotest. Sex- and age-matched controls were examined in the corresponding areas at similar time intervals. There was no statistically significant difference between groups in the sensitivity to light touch and innocuous cold in either session. Compared to controls, patients had increased sensitivity to pressure pain in the most painful area (p < 0.002), bilaterally increased sensitivity to innocuous warmth (p < 0.03), cold pain (p< 0.05) and a tendency toward bilaterally increased sensitivity to heat pain (p = 0.054) before surgery. In the painful area, patients' sensitivity to pressure pain decreased (p < 0.04) and, remaining within normal limits, sensitivity to light touch increased (p < 0.006) compared to values prior to surgery. No statistically significant differences between the groups were seen following surgery, indicating that the sensibility changes had been maintained by chronic nociceptive pain.

Low calcitonin gene-related, peptide-like immunoreactivity in cerebrospinal fluid from chronic pain patients

Cerebrospinal fluid (CSF) levels of calcitonin gene-related peptide-like activity (CGRP-LI), were determined in 35 patients with painful orthopaedic disorders and the activity was compared to that of 12 healthy controls without pain. Fourteen patients had pain from osteoarthritis of the hip or the knee, 11 had rhizopathic pain due to a herniated lumbar disc and 10 had pain from a hip fracture. In all patients, decreased CGRP-LI was observed in CSF compared to the controls. The lowest values were found in the patients with osteoarthritis, while there was less, but still significant, reduction of CGRP-LI in the patients with herniated lumbar disc and those with a hip fracture. In most of the patients, CGRP-LI was also analysed at a second lumbar puncture after operative treatment, when pain had subsided or was reduced. However, the CGRP-LI remained low after treatment, which may suggest the influence of factors other than pain.

Elevated cerebrospinal fluid substance P-like immunoreactivity in patients with painful osteoarthritis, but not in patients with rhizopatic pain from a herniated lumbar disc

Cerebrospinal fluid (CSF) levels of substance P like immunoreactivity (SPLI) were determined in 11 patients with painful osteoarthritis in hip or knee, 9 patients with rhizopatic pain from a herniated lumbar disc, and in 9 healthy volunteers without pain. The patients with osteoarthritis had increased levels of SPLI in CSF (p < 0.001) compared to the controls. A positive correlation was also seen between the CSF SPLI and the degree of pain. At a second lumbar puncture 5 months after operation, SPLI had decreased, but was still significantly higher than in the controls. No difference in CSF SPLI was seen in the patients with herniated lumbar disc compared to the controls, neither before treatment, nor at follow up CSF postoperatively. The results suggest that nociceptive joint pain is consistent with increased SPLI in CSF. Differences in SPLI in CSF may be useful to differentiate pain from various origin, and may also increase our understanding of different pain mechanisms.

Neuropeptide-converting enzymes in cerebrospinal fluid: activities increased in pain from herniated lumbar dis, but not from coxarthrosis

We measured activities of dynorphin-converting enzyme (DCE), substance P endopeptidase (SPE) and angiotensin-converting enzyme (ACE) in cerebrospinal fluid (CSF) in 13 patients with rhizopathic pain from an herniated lumbar disc, in 9 patients with pain from coxarthrosis and in 11 control patients without pain. In the patients with disc hernia and coxarthrosis, another sample of CSF was analyzed 3-12 months after treatment, when pain had subsided. The DCE activity in the patients was higher than that in both the control patients and the patients with pain from coxarthrosis (nociceptive pain). Similarly, the activity of SPE was lower in the patients with herniated lumbar disc than in controls and in the patients with coxarthrosis. After treatment, the difference in activity compared to controls was lower, but still significant in patients with herniated discs. The ACE activity did not differ from controls in patients with ischialgia, while it was increased in patients with coxarthrosis. This increase also remained after arthroplasty with pain relief. In conclusion, measurements of neuropeptides may be useful for evaluating neuropathic pain.

Piroxicam and indomethacin suppositories for painful coxarthrosis

Six orthopaedic clinics in Sweden made a comparison of the effects and side effects of Piroxicam (20 mg) and Indomethacin (100 mg) suppositories in 261 patients with painful coxarthrosis on the waiting list for total hip replacement (THR). The study was designed as a single blind study over 4 weeks. Amount of pain and range of motion was registered before the trial and compared with findings after 4 weeks, including reported side effects. Both drugs gave satisfactory pain relief without any appreciable variation on weightbearing or at rest. On the other hand, the trial showed a significant difference (p = 0.0033, Student's-test) between the two drugs as regards the frequency of side effects from the lower gastrointestinal tract, where piroxicam had a lower rate compared with indomethacin. No serious complications occurred; 16 patients dropped out, 8 in each group.

Articulotrochanteric distance in slipped capital femoral epiphysis

The difference in altitude between the proximal limit of the femoral head and the tip of the greater trochanter--the articulotrochanteric distance (ATD)--was recorded in 312 patients with slipped capital femoral epiphysis and compared with that in normal hips. The ATD was markedly reduced after severe slipping, independent of the method of treatment. In mild or moderate slippings, the ATD differed with the method of treatment. The shortest ATD was seen after osteosynthesis with AO screws. Nonoperative treatment and osteosynthesis with the Johansson nail or Nyström pin caused a slight reduction of the ATD, while no reduction was seen after hook-pinning. These differences probably reflect various degrees of damage to the subcapital growth plate, which may result in leg length difference and abduction insufficiency.

The calcar femorale as a landmark in hip physiolysis

The position of the femoral head in relation to the calcar femorale was analyzed from 120 radiographs of normal hips. A constant relationship was found, providing a method of calculating the normal position of the femoral head. The method was tested in 56 cases with physiolysis of the hip and was found to be useful in determining the degree of slipping in both adolescents and adults.

Bilaterality in slipped upper femoral epiphysis

The frequency of slipping and osteoarthritis of the contralateral hip was recorded in 260 patients with slipped upper femoral epiphysis between 1910 and 1960. Twenty-three of these patients (9%) had primary bilateral slipping, 32 (12%) had a contralateral slip diagnosed later during adolescence and a further 104 (40%) had signs of contralateral slipping at follow-up 16 to 66 years later, giving a total of 159 cases (61%) with bilateral slips. Of the 104 slippings diagnosed at follow-up, 25% showed osteoarthritis. It is concluded that, with a slipped epiphysis, prophylactic contralateral pinning should be performed to avoid slipping and to reduce the risk of osteoarthritis.

Slipped capital femoral epiphysis in southern Sweden. Long-term result with closed reduction and hip plaster spica

Seventy-two patients treated with closed reduction and hip spica for slipped capital femoral epiphysis (physiolysis colli femoris; PCF) were evaluated by questionnaire 25 to 66 years after primary treatment. Fifty-seven cases were examined with the use of clinical and radiographic methods. Pain and restricted hip function were obvious in most patients. In 25 of 72, an operation had been done in adult life for coxarthrosis. In a previously investigated group of PCF patients not actively treated, only two of 49 had had surgical treatment of coxarthrosis. Thus the results of closed reduction and hip spica are unfavorable, compared with those of nontreated cases. The results suggest a harmful influence of both reduction and hip spica.

Carpal tunnel syndrome in pregnancy. A prospective study

In this prospective study, 56 women (2.3%) of 2,358 (47% nulliparous and 53% multiparous) delivered during a 12-month period at the Department of Obstetrics and Gynecology, Malmö General Hospital, had symptoms of carpal tunnel syndrome during pregnancy. All (33 nulliparous and 23 multiparous women) were examined, at the outpatient's maternity care unit and within 4-5 weeks from the time of debut of symptoms, by a specialist in hand surgery. At that time the most common symptoms were paresthesia and nocturnal pain. Twenty-nine had signs of reduced sensibility and 14 of them had a positive two-point discrimination test. All had generalized edema. Conservative treatment with splinting of the wrist at night made 46 out of 56 symptom-free. Of the remaining 10 women, 3 had to be operated on, whereas 7 received only conservative treatment, as the expected time for parturition was very close. One of them had to be operated on after delivery. In conclusion, carpal tunnel syndrome during pregnancy is most common in primiparas with generalized edema. Conservative treatment is sufficient for symptom relief in most women (80%) but a few cases need operative intervention to abolish the severe pain and to avoid disturbances of hand function.

Slipped capital femoral epiphysis in southern Sweden 1910-1982

This work is based on 532 cases of physiolysis colli femoris (PCF) in southern Sweden from 1910 through 1982. The material was analyzed epidemiologically. Subsets were used for different investigations aimed at surveying the etiology of PCF, and long-term follow-ups were conducted after various methods of treatment. Finally, the short-term results after hook-pinning, a new device, were evaluated. After radiographic examination of anatomic specimens and normal hips, a method to diagnose and grade PCF was developed. The calcar femoral was found to be of constant shape and position and was used as a landmark to which the position of the femoral head was related. The advantage of this method is that it is easy to use and it is able to determine PCF also after growthplate closure. Epidemiologic analysis of the total material revealed large changes during the 20th century. The disease is more common in males than in females, but the male predominance has decreased from about 90 per cent to about 60 per cent during the period of investigation. Mean age at onset of slipping has decreased by about 3 years in males to 12.7 years and by about 1 year in females to 11.8 years. The incidence has followed a periodic pattern with peaks approximately every 20th year. The mean incidence was 6/10,000 in boys and 3/10,000 in girls. Boys living in the country have always been at higher risk than those living in cities. They were also at higher risk of sustaining bilateral slipping. In girls, there is a seasonal variation, with a higher incidence between May and August. The etiologic investigations dealt with hereditary, mechanical, and hormonal aspects. Radiographic examination revealed PCF in about 10 per cent of the first-degree relatives of 50 consecutive patients with PCF. One third of the families had 2 or more members with PCF. This familial accumulation is much higher than shown in earlier investigations based on questionnaires or clinical reports, and higher than expected from the incidence calculations. The growth analysis using the ICP model showed in both sexes an above average body height before puberty. However, at maturity the heights were almost normal, and accordingly the pubertal gain in height was lower than normal. Both the boys and the girls were markedly overweight before puberty and remained so at maturity. The ICP model accords with what is known about hormonal regulation of growth, and the growth abnormalities indicate a disturbed hormonal growth regulation.(ABSTRACT TRUNCATED AT 400 WORDS)

Slipped capital femoral epiphysis in southern Sweden. Long-term results after femoral neck osteotomy

Opinions differ concerning the treatment of choice for severe slipped capital femoral epiphysis, probably due to the lack of long-term follow-up evaluations on the different methods of treatment. A series of 33 patients with severe slipped capital femoral epiphysis, treated per primam with wedge osteotomy of the femoral neck, were radiographically and clinically reexamined an average of 28 years (range, 16-32 years) after the operation. Segmental collapse and/or chondrolysis developed in ten patients. Nine of these patients were available for reexamination and all had severe arthrosis with poor function. Arthrosis developed in nine of the 19 patients without signs of segmental collapse or chondrolysis; these patients had a satisfactory joint function. This series was compared with another series (from the same orthopedic departments) of patients with severe slip without any primary treatment. The long-term results in these two groups were similar; consequently, the value of realignment by wedge osteotomy of the femoral neck is questionable.

Vitality of the slipped capital femoral epiphysis. Preoperative evaluation by tetracycline labeling

In 25 cases with 29 slipped capital femoral epiphyses, treated with bilateral pinning, tetracycline was administrated preoperatively. Biopsies from the femoral head and the trochanteric region were analyzed by fluorescence microscopy. All had normal tetracycline labeling except the only patient with an acute severe slip.

Epidemiology of slipped capital femoral epiphysis in southern Sweden

Five hundred thirty-two cases of slipped capital femoral epiphysis (physiolysis colli femoris--PCF) treated at three orthopedic departments in southern Sweden between 1910 and 1982 were used for epidemiologic studies. Three hundred twenty-five cases came from a well-defined area and were used for incidence analyses. During the whole period of investigation, the disease was more common in men than in women. The difference was more pronounced in the earlier years of the investigation and among patients living in the country compared with patients living in the city. The mean age at onset of slipping has decreased in men from 16.0 to 12.7 years and has decreased in women from 12.6 to 11.8 years since the beginning of the century. The left hip is affected more often than is the right, especially in men, but during the past decades there has been a tendency toward equalization. Bilateral slipping was evident in 25.4% of the men and in 17.7% of the women. Men living outside the city were at higher risk for bilateral involvement than were men living in the city. In women, the situation was the opposite. The incidence has followed a periodic pattern with peaks approximately every 20th year. The mean incidence (number of cases/10,000 living born) during the period of growth was 6.1 in men and 3.0 in women. The maximal risk is supposed to be 25.7 in men and 20.5 in women. Men living in the country have always been at higher risk compared with men living in the city. Since the fifties, the incidence in women has also been higher in those living in the country. In women, the incidence was significantly higher between May and August. No seasonal variations were seen in men.

Slipped capital femoral epiphysis in southern Sweden. Long-term result with no treatment or symptomatic primary treatment

Forty-nine cases of slipped capital femoral epiphysis or physiolysis colli femoris (PCF) without primary treatment were evaluated 20-60 years after diagnosis by questionnaire and in 44 cases by clinical and radiographic reexamination. The cases represent PCF cases without primary treatment from three different orthopedic centers from 1910 to 1960. Only a few had restrictions in working capacity or social life. Two of these 49 cases have required surgery because of secondary arthrosis, far fewer than were found in a comparable group of cases treated with closed reduction and hip spica.