Capsular distance in the hip of the healthy child – normal values with sonography and MR imaging

Purpose: To determine the normal values of the anterior and posterior capsular distances of the hip joint in healthy children by means of US, using MR imaging as reference, and to evaluate any possible correlation between age, length, weight and anterior capsular distance (ACD).

Material and Methods: In our first study both hips in 14 healthy children (5-18 years old) were examined with US and MR to obtain measurements of the ACD and the posterior capsular distance (PCD). The distance from the anterior or posterior aspect of the femoral neck to the anterior or posterior aspect, respectively, of the outer limit of the capsule was determined. The distances were measured both with the hips in spontaneous external rotation of 10-15° and in internal rotation of 45°. In our second study, both hips in 28 healthy children (3-16 years old) were examined with US to determine the ACD. Age, length and weight were recorded.

Results: Study I: There was good correlation between the US and MR measurements in all positions. The ACD measured by US was significantly increased in inward rotation of the hip. Study II: There was no correlation between ACD and age, length or weight.

Conclusion: The PCD of the hip joint can be accurately measured by US with the hip in internal rotation of 45°. When compared with MR values, the ACD measured by US was dependent on the degree of rotation of the leg and increased significantly in internal rotation. Because the outer limit of the external layer of the joint capsule is sonographically more distinct, we suggest that the capsular distance should be measured from the outer limit of the joint capsule to the anterior or posterior aspect of the femoral neck. The measurement should be made perpendicular to the femoral neck, at the position where the greatest numerical value is obtained.

Cervical spine surgery in rheumatoid arthritis. A Swedish nation-wide registration of 83 patients

OBJECTIVE

To investigate diagnostic methods, surgical methods and indications, early complications and short term outcome of cervical spine surgery for rheumatoid arthritis (RA).

METHODS

A nation-wide registration of rheumatoid cervical spine surgery carried out in Sweden during 1993.

RESULTS

Eighty-six (74 primary) procedures in 83 patients were reported from 11 hospitals. Pain was a more common indication for surgery than was neurologic impairment. C1-C2 instability or subluxation was present in 66/82, subaxial subluxations in 27/82 and atlantoaxial impaction in 10/82 procedures (data partly missing in one case). Indications for surgery and preoperative investigations were found to be reasonably uniform, but surgical methods and post-operative care varied between hospitals. Posterior fusion was performed in 76 patients. C1-C2 wiring with bone grafting was the most common procedure followed by occipito-cervical fusion with wires and bone cement. Subaxial cervical decompression without fusion, posterior fusion with onlay graft only, and carbon fiber grafts were used in a small number of patients. Total mortality was 5/83. The early complication rate was low, but 17 patients showed recurrent subluxation at follow-up at median 7 (1-17) months. Seven of them required reoperation in the same segment.

CONCLUSION

The variation in treatment policy and number of operated patients in the different hospitals speak in favor for centralization of cervical spine surgery in RA. New methods for C1-C2-fusion need to be evaluated.

OP-1 for cervical spine fusion: bridging bone in only 1 of 4 rheumatoid patients but prednisolone did not inhibit bone induction in rats

We used OP-1 (also called BMP-7) on a collagen type-1 carrier in atlanto-axial posterior fusions to promote bony healing after wire fixation. 4 patients who had instability between the atlas and axis due to rheumatoid disease received the implants. The patients were examined with conventional radiography postoperatively at 2, 6 and 10 months. In 3 patients, no new bone formation was detectable. In 1 patient, new bone bridged the fusion site at 6 months. 3 patients were on chronic steroid treatment, including the patient in whom bone formation was detected. To determine whether steroid treatment could be responsible for the low rate of bone induction, 24 rats each received OP-1 implants in an abdominal muscle pouch. They were divided into 3 groups receiving saline, 0.1 or 1.0 mg/kg BW of prednisolone daily until they were killed 3 weeks postoperatively. Specimens were decalcified for histology and the amount of calcium in the decalcifying solution was measured. All groups showed ossicles induced by OP-1, and no effect of prednisolone was detected. Thus the failures in the patients may have causes other than prednisolone treatment.

Cervical laminectomy without fusion in patients with rheumatoid arthritis

OBJECT

The authors performed a prospective study to determine whether cervical laminectomy without simultaneous fusion results in spinal instability.

METHODS

Because of clinical and radiographic signs of cord compression, 15 patients with rheumatoid arthritis (including one with Bechterew's disease) and severe involvement of the cervical spine underwent decompressive laminectomy without fusion performed on one or more levels. Preoperative flexion-extension radiographs demonstrated dislocation but no signs of instability at the level of cord compression. Clinical and radiological reexamination were performed twice at a median of 15 months (6-24 months) and 43 months (28-72 months) postoperatively. One patient developed severe vertical translocation 28 months after undergoing a C-1 laminectomy, which led to sudden tetraplegia. She required reoperation in which posterior fusion was performed. No signs of additional instability at the operated levels were found in the remaining 14 patients. In three patients increased but stable dislocation was demonstrated. The results of clinical examination were favorable in most patients, with improvement of neurological symptoms and less pain.

CONCLUSIONS

The authors conclude that decompressive laminectomy in which the facet joints are preserved can be performed in the rheumatoid arthritis-affected cervical spine in selected patients in whom signs of cord compression are demonstrated, but in whom radiographic and preoperative signs of instability are not. Performing a simultaneous fusion procedure does not always appear necessary. Vertical translocation must be detected early, and if present, a C-1 laminectomy should be followed by occipitocervical fusion.

Interposition arthroplasty of the elbow with rheumatoid arthritis

Radiographic bone loss and clinical outcome were evaluated at a median of 6 years after interposition arthroplasty was performed in 35 elbows with rheumatoid arthritis. Seven early postoperative complications, two major and five minor, occurred. Three elbows subsequently required total elbow replacement. Clinical results were good in terms of pain relief but only fair in terms of joint mobility and stability. Radiographic elbow destruction progressed to a higher Larsen stage in half of the elbows. Measurements revealed humeral bone loss in two thirds of the elbows and ulnar bone loss in one third. In comparison with total elbow replacement, the long-term results of interposition arthroplasty were found to be inferior, with a total elbow replacement being required in one tenth of the elbows in the long term. In addition, bone loss often became extensive, making reoperation difficult or impossible. The authors recommend total elbow replacement as the first choice in the surgical treatment of the painful elbow with rheumatoid arthritis and cartilage destruction.

Short-term complications of the lateral approach for non-constrained elbow replacement. Follow-up of 50 rheumatoid elbows

We reviewed 50 capitellocondylar elbow replacements performed by the lateral approach in 42 rheumatoid patients, at a median follow-up of three years. There were two major and 17 minor complications; 18 were early and one was late. Eight elbows required reoperation: soft-tissue surgery was performed in seven and prosthesis removal in one because of a deep infection. There were few problems of instability, but one patient sustained a traumatic dislocation which was stabilised after ligament reconstruction. Wound healing was delayed in two of five elbows which had been immobilised postoperatively for only five days, but healing was rapid in 45 elbows immobilised for 12 days. There was transient ulnar-nerve palsy postoperatively in 11 patients, with permanent palsy in three. All elbows were painfree or only slightly painful at follow-up; 49 were stable and 43 had a range of motion sufficient for activities of daily living. Radiological loosening of the humeral component was suspected in one asymptomatic elbow. The lateral approach is recommended for use with the capitellocondylar type of prosthesis in rheumatoid elbows with reasonably well-preserved bone stock.

Short-term complications of the lateral approach for non-constrained elbow replacement. Follow-up of 50 rheumatoid elbows

We reviewed 50 capitellocondylar elbow replacements performed by the lateral approach in 42 rheumatoid patients, at a median follow-up of three years. There were two major and 17 minor complications; 18 were early and one was late. Eight elbows required reoperation: soft-tissue surgery was performed in seven and prosthesis removal in one because of a deep infection. There were few problems of instability, but one patient sustained a traumatic dislocation which was stabilised after ligament reconstruction. Wound healing was delayed in two of five elbows which had been immobilised postoperatively for only five days, but healing was rapid in 45 elbows immobilised for 12 days. There was transient ulnar-nerve palsy postoperatively in 11 patients, with permanent palsy in three. All elbows were painfree or only slightly painful at follow-up; 49 were stable and 43 had a range of motion sufficient for activities of daily living. Radiological loosening of the humeral component was suspected in one asymptomatic elbow. The lateral approach is recommended for use with the capitellocondylar type of prosthesis in rheumatoid elbows with reasonably well-preserved bone stock.

Intraoperative monitoring of ulnar nerve function during replacement of the rheumatoid elbow via the lateral approach

Neurography of the ulnar nerve was performed pre-, intra- and postoperatively in 8 arms of 7 patients with rheumatoid arthritis operated on with total elbow replacement via the lateral approach. Ulnar nerve decompression was performed in 4 elbows before implantation. A reduction in the amplitude of compound muscle action potential (CMAP) recorded from the abductor digiti minimi on stimulation of the ulnar nerve in the axilla, was observed during elbow dislocation at surgery in all patients, in 5 cases transiently and in 3 cases until the end of surgery. The ulnar nerve had been decompressed in all patients with lasting amplitude reduction. One of them had a mild sensory ulnar nerve palsy, while the other 2 had normal nerve function at the postoperative clinical examination. All 3 had a reduction in the amplitude of compound sensory nerve action potential (SNAP) and 2 of them also in CMAP amplitude at the postoperative neurographic examination. In patients with transient reduction during surgery, the CMAP amplitude quickly normalized on relocation of the elbow and both the SNAP and the CMAP were preserved at the postoperative neurographic examination. The authors conclude that dislocation of the laterally approached elbow carries a risk of ulnar nerve injury, which is not prevented by decompression of the ulnar nerve, but frequent relocation of the elbow during surgery seems important. It is suggested that the ulnar nerve should not be decompressed routinely, and that the dislocated elbow should be frequently relocated.

Occipito-cervical fixation in rheumatoid arthritis--an analysis of surgical risk factors in 163 patients

163 patients with rheumatoid arthritis (RA) and atlanto-axial subluxation treated by posterior occipito-cervical fixation (OCF) over a period of twenty-one years (November 1970-January 1991) were followed. Common complaints prior to surgery were occipital headache, neck pain, radicular pain and myelopathy. The mean age at time of surgery was 61 years. The mean follow-up time was 54 months. Clinical improvement was obtained in 88% of the patients, whereas 7% were unchanged and 5% had progressive symptoms in spite of surgery. There was no pre-operative or immediate postoperative mortality. In 79 patients, one or more potential surgical risk factors were identified. Twenty-four reoperations were performed in the neck. The most common cause for reoperation was mechanical failure due to wire-break or spinous process fracture. Wound infection in the neck was recorded in 16 patients. Five were deep and required removal of the fixation material. Following OCF, new or progressive subaxial subluxation (SAS) led to further surgery in 4%. The study offers support for the beneficial effect of OCF in rheumatoid AAS. We conclude that, in spite of a number of identified risk factors, OCF with the Brattström-Granholm technique remains a safe and effective method for stabilization of upper cervical subluxations in RA.

Bovine bone grafting in occipito-cervical fusion for atlanto-axial instability in rheumatoid arthritis

Bovine bone chips (Surgibone) were used in occipito-cervical fusion in nine patients with atlanto-axial instability due to rheumatoid arthritis. The patients were examined with CT 12-15 months after surgery. Graft resorbtion was observed in one patient. The other 8 patients showed preserved grafts, in most cases the grafts appeared to be in contact with the underlying bone. One patient was revised, and at the grafted site a bony bridge was found. In conclusion, the use of bovine chips in posterior occipito-cervical fusion will not lead to predictable bone union. However, there seem to be exceptions to that rule.

Surface replacement of the humeral head in the rheumatoid shoulder

The clinical results obtained an average of 4.2 years after resurfacing of the humeral head in 72 rheumatoid shoulders showed 94% of the patients being pleased regarding pain relief and 82% reporting improved shoulder mobility. Shoulder function was significantly improved. The radiographs were analyzed regarding the position of the humeral head resurfacing cup, proximal migration of the humerus, and glenoid attrition during the follow-up period. Change of the distance between the superior margin of the cup and the greater tuberosity and/or change of inclination of the prosthesis were regarded as signs of prosthetic loosening. With that definition, 25% of the cups were found to be loose at follow-up. Prosthetic loosening, however, had no bearing on the clinical result. Also, no relationship was found between the position of the cup and the clinical outcome. Neither progressive proximal migration of the humerus in 38% of the shoulders nor central attrition of the glenoid in 22% of the shoulders showed any relationship to gain of mobility, pain relief, or functional ability.

Technetium-99m-nanocolloid scintigraphy in orthopedic infections: a comparison with indium-111-labeled leukocytes

Twenty-three patients with clinically suspected acute or chronic osteomyelitis and 21 patients with suspected joint prosthetic infection underwent scintigraphy using both 99mTc-nanocolloid and 111In-labeled leukocytes. The scintigrams of the two tracers were blindly interpreted by three independent observers. Their evaluations showed high correspondence. Patients were classified as having no infection, probable infection or proven infection according to specific criteria which included results of bacteriological cultures and histopathological examinations. For proven and probable infection taken together, the sensitivity with 99mTc-nanocolloid was 94%, the specificity 84% and the accuracy 87%, compared with 75%, 90% and 85% with 111In-labeled leukocytes. We conclude that 99mTc-nanocolloid scintigraphy is at least equivalent with 111In-leucocyte scintigraphy, and its additional advantages are shorter examination time, less complexity and better radiation dosimetry.

Comparison of talonavicular dowel arthrodesis utilizing autogenous bone versus defatted bank bone

A simple dowel arthrodesis of the talonavicular joint in an early stage of destruction can reduce pain and prevent the development of valgus deformity in the rheumatoid hindfoot. Previously, we used autogenous dowels made from the iliac crest. In order to facilitate the operation and to get a better fitting dowel, we tried defatted cancellous allograft dowels from which marrow tissue had been removed. The dowels were prepared from femoral heads in our surgical bone bank. At operation, the dowels were embedded in fresh marrow aspirate from the iliac crest and the arthrodeses were stabilized with a staple. Results were evaluated by clinical examination and radiography. The results of four patients were compared with an earlier study of eight patients using autogenous dowels taken from the iliac crest. With both techniques, the patients were relieved of pain in the talonavicular joint, but some had pain from other hindfoot joints. With autogenous dowels, all eight patients healed with radiographic bony union, but with allogenous dowels, the four patients developed fibrotic nonunion. The results indicate that talonavicular arthrodesis should be made using only autologous dowels.

Metal backing improves the survival of surface replacement of the hip

Nineteen patients with juvenile chronic arthritis underwent 29 resurfacing hip arthroplasties. In 22 the original all-plastic Wagner acetabular component was used and in 7 the metal-backed Wagner-Tillmann component. After a mean of 11 (range 8-13) years 19 of the Wagner acetabular components had been revised and another 2 showed radiographic loosening. After a mean of 7 (range 5-9) years no metal-backed acetabular cup had been revised and only 1 was definitely loose.

Hyperthermia during occipito-cervical fusion with acrylic cement. Epidural thermometry in 23 cases

In 22 patients, 23 posterior occipito-cervical fusions using acrylic cement were studied; 18 had seropositive rheumatoid arthritis and 4 traumatic atlanto-axial instability. The mean age was 60 (39-75) years. During the curing of the cement, epidural temperature measurements were performed over the cerebellum and between the foramen magnum and C1. Temperatures up to 69 degrees C were recorded. Cooling with profuse surface irrigation using normal saline solution or precooled 8 degrees C fluid did not influence the maximal temperatures recorded under the cement. Even though no gross neurological damage was noted, the epidural temperatures in occipito-cervical fusion with acrylic cement can be of sufficient degree to be hazardous; surface irrigation does not seem to be an effective way to reduce this risk.

Talonavicular arthrodesis in the rheumatoid foot

Arthrodesis of the talonavicular joint with a cylindrical dowel was performed in 19 feet in 17 rheumatoid patients with arthritic destruction of the talonavicular joint, but without fixed hindfoot deformity. Osseous union was achieved in 12 feet, but all patients experienced pain relief and no foot showed progressive valgus deformity of the hindfoot during follow-up. Staple fixation seemed to promote osseous union. The procedure, easy to perform and requiring only 6 weeks of immobilization, may, in the absence of fixed hindfoot deformity, supersede triple arthrodesis in rheumatoid patients with hindfoot arthritis.

Severe aseptic synovitis of the knee after biodegradable internal fixation. A case report

Biodegradable rods made of polyglycolide (Dexon, Biofix) or lactide-glycolide copolymer (Vicryl) have been used for the past 5 years for internal fixation of a variety of fractures and osteotomies (Böstman et al. 1989, 1990b). Experience from using such rods for fixation of intraarticular osteochondral lesions seems to be less extensive. We report a case of severe synovial reaction to biodegradable rods used for fixation of osteochondritis dissecans of the knee and discuss possible reasons for the increased risk of foreign-body reactions when these rods are used intraarticularly.

MR imaging of the knee in acute rheumatoid arthritis: synovial uptake of gadolinium-DOTA

In patients with rheumatoid arthritis, the presence of acute synovial inflammation is an indication of the activity of the disease. It is an important finding because it often influences therapeutic decisions. However, acute synovitis may be difficult to detect by clinical examination, especially if a joint effusion also is present. As gadolinium tetra-azacyclododecane tetraacetic acid (Gd-DOTA) can be expected to accumulate in areas of acute inflammation, we studied the value of Gd-DOTA-enhanced MR to determine the presence of acute synovitis. Nine patients with current knee symptoms underwent MR examination of the knee. Short and long TR/TE MR images were obtained with a 0.3-T magnet before and immediately after IV administration of Gd-DOTA. A 15-min delayed short TR/TE image also was obtained. Of eight patients with moderate to severe clinical evidence of acute synovitis, six had marked increase and two had moderate increase in signal intensity from synovial tissue on the short TR/TE image obtained immediately after administration of contrast material. In the ninth patient, who had minimal synovitis clinically, the signal from the synovium did not change after administration of contrast material. No difference was seen between the enhancement pattern on the immediate and the 15-min delayed images. These results suggest that Gd-DOTA is taken up by inflamed synovium and that Gd-DOTA-enhanced MR scans may be useful in detecting acute synovitis in patients with rheumatoid arthritis.

Humeral cup fixation in rheumatoid shoulders. Roentgen stereophotogrammetry of 12 cases

Twelve shoulders in 10 patients with rheumatoid arthritis were treated with cemented cup hemiarthroplasty and examined by roentgen stereo photogrammetry during the first year after surgery. One cup migrated 0.5 mm while 11 remained well fixed. Our findings suggest that long-term prosthetic fixation may be achieved.

Fracture of the tibial tray of the PCA knee. A case report of early failure caused by improper design

Knee prostheses with metal backing of the polyethylene tibial component are nowadays used almost universally. Eight cases of fracture of the metal tray are reported in the literature. We present a case in which the failure could be expected because of improper design of the tibial tray.

Cartilage derived proteoglycans in body fluids of children. Inverse correlation with age

We have previously shown synovial fluid (SF) proteoglycan concentrations to be sensitive markers of altered cartilage metabolism in arthritis. We determined the proteoglycan concentrations in sera and SF from 23 patients with juvenile chronic arthritis and in sera from 30 healthy children by a specific enzyme linked immunosorbent assay. In both groups of children, decreasing concentrations of proteoglycans were seen during growth. Changes were most marked at the age of 12-13. The serum levels were higher in the healthy children. Our results suggest an age related metabolic change of articular cartilage, resulting in diminished release of proteoglycans to SF and blood with growing age up to 20 years. Measurement of proteoglycans could be a useful tool for studying this process.

Failure of the Wadsworth elbow. Nineteen cases of rheumatoid arthritis followed for 5 years

Nineteen Wadsworth elbow prostheses were inserted in 15 patients with rheumatoid arthritis during the 4 years 1979-1982. The patients were followed prospectively for an average of 5.7 years. Five elbows were revised because of mechanical loosening and one because of deep infection. Of the remaining 13 prostheses, there were radiographic signs of loosening in 8 cases.

Femoral head necrosis in juvenile chronic arthritis

Radiographic signs of ischemic necrosis of the femoral head in terms of abnormal epiphysis and caput indices were found in 30/72 hips in 36 children with hip pain or limitation of motion among 206 children, consecutively admitted during 15 months because of juvenile chronic arthritis. Nine out of 10 hips with obvious signs of femoral head necrosis showed a sclerotic rim at the base of the femoral neck, confirming an earlier episode of ischemic damage to the epiphysis and growth plate. Femoral head necrosis in children with juvenile chronic arthritis seems to be more common than previously reported, and may be caused by circulatory disturbance secondary to increased intraarticular pressure due to synovitis and/or effusion, or to treatment with passive extension of the hip. This should be considered in the treatment and the follow-up of these children.

Hip socket wear due to component mismatch. A case report

A total hip replacement with loosening of the femoral component was revised. The original femoral component with a 35-mm head was exchanged for one with a 32-mm head. The mismatch caused extensive wear of the acetabular component. The importance of preoperative planning in revision surgery is stressed.

Position of shoulder arthrodesis measured with Moiré photography

A new method for measuring the position of a shoulder arthrodesis is presented. With Moiré photography and two mirrors, it is possible to find the neutral position of the scapula and to record the position of the humerus with great accuracy.

Alkaptonuria and ochronosis in three siblings. Ascorbic acid treatment monitored by urinary HGA excretion

Patients with alkaptonuria lack homogentisate 1,2-dioxygenase leading to retention of homogentistic acid (HGA) in body fluids and eventually to tissue deposition of oxidation products, giving rise to the clinical picture of ochronosis. Ascorbic acid is a known inhibitor of the enzyme which catalyses the oxidation of homogentisic acid (HGA) to the polymer with affinity for collagen and was used in the treatment of three siblings with alkaptonuria. Ascorbic acid 500 mg bid was administered for 12 months. Two of the siblings tolerated the treatment, and in one the symptoms improved, whereas in the other they worsened. Plasma and urinary levels of HGA were monitored with a new HPLC method. Ascorbic acid is not effective in the treatment of symptomatic ochronosis.

Pigmented villonodular synovitis of the hip joint

Diffuse pigmented villonodular synovitis of the hip joint is uncommon. The disease is usually slowly progressive with accompanying pain and limitation of movement. Radiographs often show cystic radiolucent defects in the acetabulum and femoral head, but the joint space remains preserved until late. Two cases are reported, both with a primary diagnosis of coxarthrosis which had been treated unsuccessfully by intertrochanteric osteotomy. A correct diagnosis was not reached until the hip joint was explored. The progress of radiographic changes over a period of eight years is demonstrated in one case. Arthroscopy and synovial biopsy should be considered in young adults with hip pain of unknown origin.

Lateral elbow pain caused by anconeus compartment syndrome. A case report

A carpenter presented with lateral elbow pain and bulging tenderness and impaired function of the anconeus muscle. Computed tomography showed enlargement of the muscle. The intracompartmental pressure was increased at rest, during and after exercise, and had a prolonged recovery time. The patient recovered immediately after fasciotomy of the anconeus muscle, and 6 months later he was still free from pain and intracompartmental pressures were normal.

Revision knee arthroplasty in rheumatoid arthritis

Seventy-six revised total knee arthroplasties (TKAs) performed for mechanical, nonseptic failure of the primary arthroplasty in 62 rheumatoid arthritis patients were investigated. The revisions were performed with McIntosh, Marmor, Attenborough, Guepar, and various types of tricompartmental prostheses. Twenty-one of the 76 revisions subsequently failed. Fifteen were mechanical failures and six were deep infections. Thirteen of the 21 failures were treated with another arthroplasty, six with arthrodesis, and two with antibiotics only. After an average of 60 months, 48 of the surviving arthroplasties were examined clinically and roentgenographically. At follow-up examination, eight were clinical failures. One-half of the McIntosh and Marmor arthroplasties and one-third of the Attenborough and Guepar arthroplasties, altogether 17 cases, showed signs of potential roentgenographic failure. The majority of the revised TKAs classified as roentgenographic failures were clinically successful or acceptable. Revision of TKAs in noninfected rheumatoid patients can be performed with acceptable clinical results but with a significantly higher failure rate than after primary procedures.

Stapling of the knee in juvenile chronic arthritis

Stapling of the distal medial femur and/or proximal tibia was performed in 17 juvenile chronic arthritic knees with progressive valgus deformity. Correction with less than 5 degrees of residual valgus deformity was obtained in all but two knees. Five knees were stapled for correction of progressive leg length discrepancy. Equality of leg length was obtained in two, slight undercorrection in two, and overcorrection in one patient. Careful supervision of the patient is recommended because of difficulties in using existing methods for growth prediction. The rate of correction differs considerably between patients because of differences in age, type of disease, and medical treatment.

Cup arthroplasty of the rheumatoid shoulder

Hemiarthroplasty of the humeral head, using a stainless steel cup, was performed in 26 shoulders of patients with rheumatoid arthritis who had severe pain and loss of function. All the shoulders were Larsen's radiographic Grade 4 or 5. After 2 (1-5) years, all the shoulders were painless and had satisfactory function. Partial radiolucent zones exceeding 1 mm were seen in three shoulders.

Sonography, arthroscopy, and intracapsular pressure in juvenile chronic arthritis of the hip

Sonography was used in the preoperative evaluation of the hip joint in 14 patients with juvenile chronic arthritis (JCA). The joint capsule distension found at sonography and the intracapsular pressure were increased in patients with severe synovitis revealed at arthroscopy. Sonography and intracapsular pressure-recording can be recommended for assessments of synovitis of the hip joint in JCA.

Soft tissue release for knee flexion contracture in juvenile chronic arthritis

Twenty-nine soft tissue releases for knee flexion contracture were performed in 23 children 2-15 years of age with juvenile chronic arthritis. The average duration of knee joint involvement was 4.6 years (range 1-11 years), and the mean age at operation was 8.6 years. Twenty-one of the 29 knee joints had a fixed flexion deformity exceeding 15 degrees preoperatively. Twenty-five knees were followed up for a mean period of 3.9 years (range 1-8 years), at which time only eight knees had a flexion deformity exceeding 15 degrees. There was a lasting effect of the release operations, and no significant complications were encountered. It is concluded that the procedure is worthwhile.

Loosening of the porous coating of bicompartmental prostheses in patients with rheumatoid arthritis

Thirty-four porous-coated anatomical (PCA) total knee arthroplasties in twenty-eight patients with rheumatoid arthritis were followed for an average of seventeen months. In these thirty-four knees, twenty-three tibial and fifteen femoral components were cemented. The rest were uncemented. At follow-up, more than half of the knees (nineteen of thirty-four) showed radiographic evidence of displacement of some of the beads from the porous coating. In fourteen knees the beads loosened more than three months postoperatively, and all of these knees had a radiolucent zone. Six knees had beads within the joint. Eight of nine non-cemented tibial components (excluding one tibial component) and five of the nineteen femoral components that were not cemented showed late loosening of beads (after three months). This study indicates that the metallurgical technique for porous coating with heat-sintered cobalt-chromium beads does not produce a coating that is sufficiently strong to prevent loosening in the case of the porous-coated anatomical prosthesis. The long-term clinical relevance of our findings is unclear. The mechanical strength of the porous coating on the prosthetic surface should be improved and the prosthesis should be tested in limited clinical studies before cementless fixation can be recommended.

Synovectomy of the knee in juvenile chronic arthritis. A retrospective, consecutive follow-up study

We report 60 synovectomies of the knee in 51 children with juvenile chronic arthritis. Synovitis had been present for an average of 5 years and the average age at operation was 13 years. Results were evaluated in terms of pain, knee movement, relapse of synovitis and radiological change during a follow-up averaging 7.5 years. The relief of pain was rewarding and there was a slight postoperative gain in range of knee movement in most cases. The older the patient at onset of disease, the greater the risk of pain during follow-up. Progressive joint destruction was more common in younger patients, those with systemic or polyarticular disease, and those with highly active disease at the time of operation. Recurrence of synovitis was more frequent in patients who had their operation in a phase of high disease activity; this occurred most often in patients with polyarticular disease.

Arthroscopy of the knee in juvenile chronic arthritis

Arthroscopy of 35 knee joints in 29 children with juvenile chronic arthritis (JCA) was performed to aid in the overall evaluation of the joint and the decision on further medical or surgical treatment. Arthroscopy showed cartilage destruction earlier than radiography. In five knees, synovectomy was performed by another surgeon immediately after the arthroscopy and the findings at operation agreed with those made at arthroscopy. Thus the validity of the method seems good and arthroscopy is valuable for early information on the state of cartilage and synovial inflammation in juvenile chronic arthritic knee joints.

Radiologic classification of joint destruction in juvenile chronic arthritis

A radiologic classification of the destruction of the large joints in juvenile chronic arthritis is described. Its principles are the same as previously published by the authors for evaluation of the knee joint. Osteoporosis, enlargement or other growth disturbance of the bone ends, cyst formation, erosions or deformation of the subchondral joint surface is expressed in terms of a score. In a retrospective study of 74 examinations of the large joints in 30 patients aged 6-18 years, the suggested classification was used. The radiologic score obtained had a good correlation to the clinical findings.

Total knee replacement in juvenile chronic arthritis

Twelve patients with juvenile chronic arthritis (JCA) underwent 18 primary knee replacements during 1975-81. Eleven patients were followed for an average of six (3-9) years. Mean age at operation was 25 (18-32) years. Indications for surgery were pain and limitation of motion. Four knee joints were revised, one of them three times, due to malposition and/or mechanical loosening of the prosthetic components. At follow-up, all patients except one were satisfied with the knee replacement. All patients except one were ambulatory. Functional capacity was improved in 8 patients. The arc of motion was increased by a mean of 17 degrees. The radiographs at follow-up showed an average hip-knee-ankle (HKA) angle of 182 (173-193) degrees. In eight knee joints the tibial and/or femoral component showed a radiolucent zone at the bone-cement interface exceeding 2 mm and in four of these joints there were signs of prosthetic migration. To aid in the choice of an appropriate prosthesis for the juvenile arthritic joint, standardized measurements of the radiographic dimensions of the knee joint were made. Because of the high rate of revisions during the short observation period and the potential failure rate indicated by the radiographs at follow-up, we maintain a cautious attitude towards knee replacement in patients with JCA.

Surface replacement of the elbow in rheumatoid arthritis. Early results with the Wadsworth prosthesis

Fifteen patients with rheumatoid arthritis had 19 elbow arthroplasties with the Wadsworth type of surface replacement prosthesis. After a follow-up period averaging 30 months, 11 patients with 15 elbow arthroplasties were entirely satisfied with their freedom from pain and range of movement. Radiologically, however, the humeral component was loose in 10 of the 19 elbows and the ulnar component in 5. Two patients had reoperation, one to remove a prosthesis for early deep infection and one to exchange a humeral component which was loose. The risk of mechanical loosening is reduced by accurate positioning of the humeral component, but there is a high potential for failure. Changes in the design of the prosthesis and better instrumentation for alignment of the components are desirable. Prosthetic replacement of the elbow should still be regarded as experimental.

Radiologic classification of knee joint destruction in juvenile chronic arthritis

A new radiologic classification of juvenile chronic arthritis (JCA) of the knee joint is presented. Osteoporosis, epiphyseal enlargement, erosions, subchondral cyst formation and deformity of the joint surfaces are expressed in terms of a score. No attention is paid to the joint space or soft tissues. Thirty knee joints in 15 patients with JCA were evaluated according to the radiologic classification. There was a good correlation between the radiologic score and the clinical findings. The inter- and intraobserver variation was low. The classification system is proposed as a valuable tool for measuring the degree of knee joint destruction in evaluation of the natural course or results of treatment in JCA.

Chronic compartmental syndrome in the tensor fasciae latae muscle

Chronic compartmental syndromes have been reported in various locations in the upper and lower extremities, but to the best of the authors' knowledge it has not been described in the tensor fasciae latae muscle. Two patients, men of about 60 years of age, complained of pain on exertion and sitting associated with swelling of the tensor muscle. In both cases CT scans showed muscle enlargement. Intracompartmental pressure values were high both at rest and during exercise. After fasciotomy the patients were relieved of pain, and intracompartmental pressure values were normalized.

Intracompartmental forearm pressure during rest and exercise

To investigate whether effort-related dorsal forearm pain could be due to an increase of the intracompartmental pressure (ICP) in the dorsal forearm compartment, the normal range of the ICP at rest and during exercise was first determined in 11 volunteers using a wick catheter. The ICP at rest was 6 mm Hg (range, 2-11 mm Hg), and during exercise the pressure rose to about six times the resting level. Fourteen patients with pain in the dorsal forearm during exercise were similarly examined. In six patients the pressure at rest and/or during exercise was more than twice that of the normal persons or that of the healthy forearm. After fasciotomy four of these six patients were relieved of pain within three weeks, which might suggest a relation between ICP and pain.

The tarsal tunnel syndrome in children

There are few reports on the tarsal tunnel syndrome in children. This paper concerns 10 such children. In adults the syndrome is equally distributed among the sexes but all these children were girls. Trauma preceded the symptoms in only two cases. The symptoms differed in some aspects from those usually seen in adults. Six of the children walked with the affected foot in supination. Three of the six, and one other, used crutches at intervals. All were operated on and at follow-up nine were symptom-free and the tenth had improved.

Traumatic bowing of the forearm: a case report

In a 16-year-old girl, the forearm was caught between rollers in a textile factory. The tangential force caused massive swelling and one week later bowing of the forearm was noticed. One month and 3 months later the bowing was unchanged, and caused 30 degrees limitation of pronation while supination was normal. Bowing of the forearm bones in children following trauma, interperted as a plastic deformation of bone, is only recently recognized as a clinical and roentgenological entity.