Search

Background: A bone-anchored limb (BAL) is an alternative to a traditional socket-type prosthesis for people with transfemoral amputation. Early laboratory-based evidence suggests improvement in joint and limb loading mechanics during walking with a BAL compared to socket prosthesis use. However, changes in cumulative joint and limb loading measures, which may be predictive of degenerative joint disease progression, remain unknown., Research Question: Do cumulative total limb and hip joint loading during walking change using a BAL for people with unilateral transfemoral amputation, compared to prior socket prosthesis use?, Methods: A case-series cohort of eight participants with prior unilateral transfemoral amputation who underwent BAL hardware implantation surgery were retrospectively analyzed (4 M/4 F; BMI: 27.7 ± 3.1 kg/m 2 ; age: 50.4 ± 10.2 years). Daily step count and whole-body motion capture data were collected before (using socket prosthesis) and one-year after BAL hardware implantation. Cumulative total limb and hip joint loading and between-limb loading symmetry metrics were calculated during overground walking at both time points and compared using Cohen's d effect sizes., Results: One year after BAL hardware implantation, participants demonstrated bilateral increases in cumulative total limb loading (amputated: d = -0.65; intact: d = -0.72) and frontal-plane hip moment (amputated: d = -1.29; intact: d = -1.68). Total limb loading and hip joint loading in all planes remained asymmetric over time, with relative overloading of the intact limb in all variables of interest at the one-year point., Significance: Despite increases in cumulative total limb and hip joint loading, between-limb loading asymmetries persist. Habitual loading asymmetry has been implicated in contributing to negative long-term joint health and onset or progression of degenerative joint diseases. Improved understanding of methods to address habitual loading asymmetries is needed to optimize rehabilitation and long-term joint health as people with transfemoral amputation increase physical activity when using a BAL., Competing Interests: Declaration of Competing Interest The authors declare that they have no known conflicting financial or personal interests that could have appeared to inappropriately influence the results presented in this work., (Published by Elsevier B.V.)

For some individuals with severe socket-related problems, prosthesis osseointegration directly connects a prosthesis to the residual limb creating a bone-anchored limb (BAL). We compared dynamic gait stability and between-limb stability symmetry, as measured by the Margin of Stability (MoS) and the Normalized Symmetry Index (NSI), for people with unilateral transfemoral amputation before and one-year after BAL implantation. The MoS provides a mechanical construct to assess dynamic gait stability and infer center of mass and limb control by relating the center of mass and velocity to the base of support. Before and one-year after BAL implantation, 19 participants walked overground at self-selected speeds. We quantified dynamic gait stability anteriorly and laterally at foot strike and at the minimum lateral MoS value. After implantation, we observed decreased lateral MoS at foot strike for the amputated (MoS mean(SD) %height; pre: 6.6(2.3), post: 5.9(1.3), d = 0.45) and intact limb (pre: 6.2(1.2), post: 5.8(1.0), d = 0.38) and increased between-limb MoS symmetry at foot strike (NSI mean(SD) %; anterior-pre: 10.3(7.3), post: 8.4(3.6), d = 0.23; lateral-pre: 18.8(12.4), post: 12.4(4.9), d = 0.47) and at minimum lateral stability (pre: 28.1(18.1), post: 19.2(6.8), d = 0.50). Center of mass control using a BAL resulted in dynamic gait stability more similar between limbs and may have reduced the adoption of functional asymmetries. We suggest that improved between-limb MoS symmetry after BAL implantation is likely due to subtle changes in individual limb MoS values at self-selected walking speeds resulting in an overall positive impact on fall risk through improved center of mass and prosthetic limb control., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [Dr. Jason W. Stoneback is a paid consultant for AQ Solutions. No additional competing financial or non-financial interests which could or appear to influence the interpretation or presentation of this work are declared]., (Published by Elsevier Ltd.)

Background: Low back pain (LBP) is more prevalent in patients with transfemoral amputation using socket prostheses than able-bodied individuals, in part due to altered spinal loading caused by aberrant lumbopelvic movement patterns. Early evidence surrounding bone-anchored limb functional outcomes is promising, yet it remains unknown if this novel prosthesis influences LBP or movement patterns known to increase its risk., Research Question: How are self-reported measures of LBP and lumbopelvic movement coordination patterns altered when using a unilateral transfemoral bone-anchored limb compared to a socket prosthesis?, Methods: Fourteen patients with unilateral transfemoral amputation scheduled to undergo intramedullary hardware implantation for bone-anchored limbs due to failed socket use were enrolled in this longitudinal observational cohort study (7 F/7 M, Age: 50.2±12.0 years). The modified Oswestry Disability Index (mODI) (self-reported questionnaire) and whole-body motion capture during overground walking were collected before (with socket prosthesis) and 12-months following bone-anchored limb implantation. Lumbopelvic total range of motion (ROM) and continuous relative phase (CRP) segment angles were calculated during 10 bilateral gait cycles. mODI, total ROM, CRP and CRP variabilities were compared between time points., Results: mODI scores were significantly reduced 12-months after intramedullary hardware implantation for the bone-anchored limb (P = 0.013). Sagittal plane trunk and pelvis total ROM during gait were reduced after implantation (P = 0.001 and P < 0.001, respectively). CRP values were increased (more anti-phase) in the sagittal plane during single limb stance and reduced (more in-phase) in the transverse plane during pre-swing of the amputated limb gait cycle (P << 0.001 and P = 0.029, respectively). No differences in CRP values were found in the frontal plane., Significance: Decreases in mODI scores and lumbopelvic ROM, paired with the changes in lumbopelvic coordination, indicate that bone-anchored limbs may reduce LBP symptoms and reduce compensatory movement patterns for people with unilateral transfemoral amputation., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Fall-related injuries are associated with muscle weakness and common during slope walking in older adults. However, no study has evaluated the relationship between muscle weakness, measured by maximal lower limb extension power, and older adults' ability to navigate slope walking for a better understanding of fall prevention. Therefore, the purpose of this study was to investigate the association between maximal lower limb extension power and joint mechanics during slope walking. Fifteen healthy older adults were tested. Lower limb extension power was measured using the Leg Extension Power Rig. Kinematic and kinetic analysis was performed during level (0°), incline (10°), and decline (10°) slope walking. Greater maximal lower limb extension power was significantly (p < .050; Cohen's f2 > 0.35) associated with multiple kinetic and kinematic joint mechanic variables across stance phase of the gait cycle during level, incline, and decline walking. These findings will allow clinicians to better educate patients and develop interventions focused on fall prevention and improving functional mobility in older adults.

Purpose: We studied the current management trends for extraperitoneal bladder injuries and evaluated the use of operative repair versus catheter drainage, and the associated complications with each approach., Materials and Methods: We prospectively collected data on bladder trauma from 20 level 1 trauma centers across the United States from 2013 to 2018. We excluded patients with intraperitoneal bladder injury and those who died within 24 hours of hospital arrival. We separated patients with extraperitoneal bladder injuries into 2 groups (catheter drainage vs operative repair) based on their initial management within the first 4 days and compared the rates of bladder injury related complications among them. Regression analyses were used to identify potential predictors of complications., Results: From 323 bladder injuries we included 157 patients with extraperitoneal bladder injuries. Concomitant injuries occurred in 139 (88%) patients with pelvic fracture seen in 79%. Sixty-seven patients (43%) initially underwent operative repair for their extraperitoneal bladder injuries. The 3 most common reasons for operative repair were severity of injury or bladder neck injury (40%), injury found during laparotomy (39%) and concern for pelvic hardware contamination (28%). Significant complications were identified in 23% and 19% of the catheter drainage and operative repair groups, respectively (p=0.55). The only statistically significant predictor for complications was bladder neck or urethral injury (RR 2.69, 95% 1.21-5.97, p=0.01)., Conclusions: In this large multi-institutional cohort, 43% of patients underwent surgical repair for initial management of extraperitoneal bladder injuries. We found no significant difference in complications between the initial management strategies of catheter drainage and operative repair. The most significant predictor for complications was concomitant urethral or bladder neck injury.

Background: The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted toward a nonoperative approach, nephrectomy remains the most common intervention for high-grade renal trauma (HGRT). We aimed to describe the contemporary management of HGRT in the United States and also evaluate clinical factors associated with nephrectomy after HGRT., Methods: From 2014 to 2017, data on HGRT (American Association for the Surgery of Trauma grades III-V) were collected from 14 participating Level-1 trauma centers. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Management was classified into three groups-expectant, conservative/minimally invasive, and open operative. Descriptive statistics were used to report management of renal trauma. Univariate and multivariate logistic mixed effect models with clustering by facility were used to look at associations between proposed risk factors and nephrectomy., Results: A total of 431 adult HGRT were recorded; 79% were male, and mechanism of injury was blunt in 71%. Injuries were graded as III, IV, and V in 236 (55%), 142 (33%), and 53 (12%), respectively. Laparotomy was performed in 169 (39%) patients. Overall, 300 (70%) patients were managed expectantly and 47 (11%) underwent conservative/minimally invasive management. Eighty-four (19%) underwent renal-related open operative management with 55 (67%) of them undergoing nephrectomy. Nephrectomy rates were 15% and 62% for grades IV and V, respectively. Penetrating injuries had significantly higher American Association for the Surgery of Trauma grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy., Conclusion: Expectant and conservative management is currently utilized in 80% of HGRT; however, the rate of nephrectomy remains high. Clinical factors, such as surrogates of hemodynamic instability and metabolic acidosis, are associated with nephrectomy for HGRT; however, higher renal injury grade and penetrating trauma remain the strongest associations., Level of Evidence: Prognostic/epidemiologic study, level III; Therapeutic study, level IV.

Polyethylene (PE) wear and osteolysis is a recognised problem with non-cross linked PE liners and first generation modular cup designs. Wear particles induce osteolysis leading to aseptic loosening. We retrospectively compared the linear PE wear and implant survival and revision rates of the Reflection Cup and the Duraloc 300. After a mean clinical follow-up of 13 years (range 11-15 years), the 2D linear PE wear-rate of the Reflection liner (n = 68) was 0.23 mm/year, with a mean total wear of 3.14 mm (1.04-7.36), SD 1.45. The wear-rate of the Duraloc 300 cups (n = 32) was 0.14 mm/year, with a mean total wear of 1.84 mm (0.55-4.63), SD 1.07. The difference in PE wear-rate as well as mean total wear was highly significant (p = 0.0001). There was a positive correlation between wear-rate and both Oxford Hip Score and Harris Hip Score (p = 0.02). Large acetabular cup size (>54 mm), HA coating on the stem and age <50 years did not influence PE wear. The higher wear-rate in the Reflection liners could be related to the EtO sterilisation. Intermediate and long-term follow-up is advisable.

Introduction: As the only femoral stem, the Exeter stem has shown acceptable results with Boneloc cement, but no long-term results have been published. The aim of this study was to evaluate the 20-year performance of Boneloc-cemented primary Exeter hip arthroplasty., Material and Methods: From March 1992 to June 1994, a total of 200 consecutive Boneloc-cemented primary hip arthroplasties were performed in 183 patients aged 26-90 years, mean 71 years. At follow-up after 18-20 years, the primary endpoint was prosthetic survival assessed by the Kaplan-Meier analysis. Secondary endpoints were clinical and radiographic follow-up examination., Results: After a mean 18.4 (17.6-19.6)-year period, 27 patients/32 hips had been revised. At endpoint revision for any reason the 20-year cumulative overall survival was 73% (95% confidence interval (CI): 49-89%); at endpoint revision for aseptic loosening the 20-year cumulative survival was 84% (95% CI: 68-96%) for the stem and 76% (95% CI: 61-92%) for the cup. Cementing technique, implant size and metal backing of the cup were not associated with revision rates. A total of 23 patients/24 hips had clinical/radiographic examination, and 10 patients/12 hips were assessed by telephone. According to patient reported evaluation, all were very satisfied or satisfied. Radiographs showed loosening of two cups and possible loosening of two stems., Conclusion: This study provides the first long-term results on Boneloc-cemented primary hip arthroplasty. The Exeter prosthesis, especially the stem, maintains the previously published acceptable survival and results despite the documented inferior quality of the cement., Funding: not relevant., Trial Registration: not relevant.

Unlabelled: During the last 25 years uncemented hip stem revision relying on diaphyseal fixation has shown improving clinical results and stem survival. The purpose of this study was to present the long-term results of hip revision with the SOLUTION stem (DePuy, Warsaw Indiana).
Ninety-three consecutive SOLUTION hip stem revisions in 84 patients with a mean age of 69 years (range 33-86 years) were reviewed. Of these, clinical and radiographic follow-up examination by an independent observer was possible in 36 hips/29 patients after mean 14 years (range 10-18 years). Stem re-revision was documented by our own files and by the Danish Hip Arthroplasty Registry. 
Stem re-revision had been performed in two hips for aseptic loosening, one due to deep infection and in one patient due to stem fracture. The 18 years cumulative survival, free of re-revision for any reason was calculated as 94.4% (88.9-99.8)% and for aseptic loosening to 97.6% (94.3-100%). Intraoperative complications were frequent with incidence of shaft fractures (14/93) and perforations (9/93) showing a significant learning curve. Mean Harris Hip Score was 85 (range 53-99). Osseointegration was seen in 34/36 stems with two stems fibrous fixated. Stress shielding was significant associated with stem diameters ≥15 mm. Severe preoperative bone deficiency had no negative bearing on stem survival and no significant influence on osseointegration of the stem or on Harris Hip Score. 
, Conclusion: Femoral stem revision with an extensively porous-coated monoblock chrome-cobalt stem seems to be a reliable and reproducible technique resulting in excellent long-term survivorship and clinical outcome. It can be used in femurs with deficient bone stock.

Background: Accelerated perioperative rehabilitation protocols following total hip and knee arthroplasties are currently being implemented worldwide, but the cost-effectiveness of these protocols from a societal perspective is not known. We compared the cost-effectiveness of an accelerated perioperative care and rehabilitation protocol with that of a more standard protocol for patients treated with total hip and knee arthroplasty., Methods: A cost-effectiveness study was undertaken as a study piggybacked on a randomized clinical trial comparing early outcomes of an accelerated and intensive postoperative rehabilitation regimen with those of a more standard rehabilitation protocol. We assessed eighty-seven patients (forty-two who received the standard protocol and forty-five who received the accelerated protocol) for a total of twelve months. Costs from the time of the patient's visit immediately before the operation to one year postoperatively were calculated with use of activity-based costing analysis. Postoperative quality-adjusted life-years (QALYs) were calculated from validated patient diaries and questionnaires at fifteen time points. The primary objective was to determine whether one intervention was dominant over the other during a twelve-month period or, if neither was dominant, to determine the incremental cost-effectiveness ratio., Results: The result of the randomized clinical trial showed the accelerated intervention to be effective, with a reduction in the length of the hospital stay and a gain in health-related quality of life at the three-month follow-up time point. The cost-effectiveness study showed the accelerated protocol to be significantly less expensive than the standard protocol (p=0.036), with an average reduction in cost of 18,880 Danish kroner (95% confidence interval, 1899 to 38,152) (approximately US $4000). Patients treated with the accelerated protocol following hip arthroplasty had an additional average gain of 0.08 QALY (95% confidence interval, 0.02 to 0.15) compared with the patients who received the standard protocol (p=0.006); this led to a 98% dominance of the accelerated protocol over the standard protocol. No significant or clinically relevant difference in the numbers of QALYs associated with the two protocols was observed for the patients treated with knee arthroplasty., Conclusions: An accelerated perioperative care and rehabilitation protocol can be both cost-saving and clinically more effective after total hip arthroplasty, whereas it can be cost-saving with no observed significant difference in effect, from a societal perspective, after knee arthroplasty.

Background: In Denmark, approximately 12,000 hip and knee arthroplasties were performed in 2006, and the hospital costs were close to US$ 110,000,000. In a randomized clinical trial, we have recently demonstrated the efficacy of accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty compared to current intervention under ideal circumstances. We do not, however, know whether these results could be reached under usual circumstances of healthcare practice. We therefore investigated whether length of stay after implementation of accelerated perioperative care and rehabilitation after hip and knee arthroplasty could be reduced in a normal healthcare setting, and how the achieved results matched those observed during the randomized clinical trial., Methods: An effectiveness study as a before-after trial was undertaken in which all elective primary total hip and total knee arthroplasty patients were divided into a before-implementation group receiving the current perioperative procedure, and an after-implementation group receiving the new accelerated perioperative care and rehabilitation procedures as provided by a new multi-disciplinary organization. We used the Breakthrough Series Collaborative Model for implementation. The primary outcome measure was in hospital length of stay (LOS), and the secondary outcome measure was adverse effects within 3 months postoperatively., Results: We included a total of 247 patients. Mean LOS was significantly (P < 0.001) reduced by 4.4 (95% CI 3.8-5.0) days after implementation of the accelerated intervention, from 8.8 (SD 3.0) days before implementation to 4.3 (SD 1.8) days after implementation. No significant differences in adverse effects were observed. LOS in this effectiveness study was significantly lower than LOS reported in the efficacy study., Conclusion: Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty was successfully and effectively implemented. Results obtained during usual hospital circumstances matched the results achieved under ideal circumstances in this group of patients.

Background: Approximately 12,000 hip and knee replacements were performed in Denmark in 2005. Accelerated perioperative interventions are currently implemented, but there is conflicting evidence regarding the effect. We therefore performed an efficacy study of an accelerated perioperative care and rehabilitation intervention in patients receiving primary total hip replacement, and both total and unicompartmental knee replacement., Methods: A randomized clinical trial was undertaken in which 87 patients were randomized to either a control group receiving the current perioperative procedure, or an intervention group receiving a new accelerated perioperative care and rehabilitation procedure. Outcome measures were length of stay (LOS) in hospital, and gain in quality of life (QOL) using EQ-5D from baseline to 3-month follow-up., Results: Mean LOS was reduced (p < 0.001) from 8 days (95% CI: 7.1-8.4) in the control group to 5 days (95% CI: 4.2-5.6) in the intervention group. This was accompanied by a greater gain in QOL of 0.08 (95% CI: 0.004-0.16) in the intervention group (p = 0.03)., Interpretation: An accelerated perioperative care and rehabilitation intervention in patients undergoing primary total hip replacement, and total or unicompartmental knee replacement is indeed effective-and of advantage to both the hospital and the patient.

The nociceptive trigeminal inhibitory (NTI) splint has been claimed to decrease the electromyographic (EMG) activity of jaw-closing muscles and relieve symptoms of various types of temporomandibular disorders (TMD) and bruxism. The present study was designed to address the question about EMG-changes during sleep. Ten patients (age: 23-39 years) with a self-report of tooth-grinding during sleep were recruited. Patients were examined at baseline and after each treatment period with the use of the Research Diagnostic Criteria for TMD. A portable EMG-device was used to record EMG-activity from the masseter muscle during sleep. The patients received two 2-week splint treatments in a randomized cross-over fashion; an NTI splint and a standard flat occlusal splint (OS). EMG data were analysed according to published criteria. Using a 10% of maximum clenching EMG-activity cut-off threshold to determine the number of EMG-events h(-1) of sleep, the NTI splint was associated with a significant reduction (9.2 +/- 3.2 events h(-1)) compared with baseline EMG (19.3 +/- 4.0; anova: P = 0.004, Tukey post hoc: P = 0.006), whereas there were no differences between the OS (16.2 +/- 4.7) and baseline EMG (19.2 +/- 4.1; P = 0.716). There were no effects of either NTI or OS on clinical outcome measures (anovas: P > 0.194). This short-term study indicated a strong inhibitory effect on EMG-activity in jaw closing muscles during sleep of the NTI, but not the OS. However, the EMG-activity was not directly related to clinical outcome. Further studies will be needed to determine long-term effects and possible side effects of the NTI splint.

The aim of this study was to compare the efficacy and safety of prolonged (35 days) thromboprophylaxis with a standard length (7 days) regimen of a low molecular weight heparin in patients undergoing total hip arthroplasty. The study was multicentre, randomised, double-blind, and prospective with two groups. Following seven days on a standard length regimen of dalteparin (5000 antifactor Xa units subcutaneously once daily starting 12 h before surgery), patients were randomized to continue the prophylaxis with either subcutaneous injections of dalteparin or placebo injections for a further 28 days. Efficacy was evaluated at the end of the study (day 35) in all patients with bilateral ascending phlebography to detect deep vein thrombosis. Bleeding complications and other adverse events were registered throughout the study period. Three hundred consecutive patients agreed to participate before the operation: 281 were finally randomised and 215 completed the study; two patients died before randomisation; 17 developed deep vein thrombosis; none developed pulmonary embolism; and five of 113 patients (4.4%, 95% CI 1-10%) developed deep vein thrombosis in the dalteparin group, compared with 12 of 102 (11.8%; 95% CI 6-20%) in the placebo group (p=0.039). Deep vein thrombosis in the proximal veins was diagnosed in one patient (0.9%; 95% CI 0-5%) in the dalteparin group, and in five (5.0%; 95% CI 2-11%) in the placebo group (p=0.076). Major bleeding was observed in one patient in the placebo group; minor bleeding complications and adverse events were equally distributed between the groups. We concluded that prolonged (35 days) thrombo prophylaxis with dalteparin is more effective than a standard length (7 days) regimen without increased risk of bleeding complications or other adverse events.

In the period 05.06.79 -31.12.91, 2037 primary total hip arthroplasties were performed, all in ultra-clean air, wearing body-exhaust system suits and all patients recieving Meticillin as prophylactic antibiotics. None of the non-cemented arthroplasties were infected and 0.61% of the cemented hip arthoplasties were infected giving a total incidence of deep infection after total hip arthroplasty in our clinic of 0.49%. The microorganism most commonly cultured was Staph. aureus, but in one hip Listeria was cultured, which is extremely rare. In the 10 patients with deep infection the infection reccurred in 30%. Patients with a revision prosthesis in situ at follow-up, had an average Harris-hip score of 79, and radiographs showed no signs of loosening or persistant infection. The rate of deep infection and the patients' condition after the revision procedures in our series are comparable to other published series.

Eleven children with simple bone cysts in the proximal humerus metaphysis were treated with intracavity infiltration of methylprednisolone acetate. Nine patients were treated once; the remainder required second injections. Five lesions resolved completely, while six healed sufficiently to eliminate the risk of pathologic fracture, and to permit physical activities without restrictions. Simple bone cysts can be treated satisfactorily with injection of methylprednisolone acetate, thus obviating surgery.

Sixty-two (11 women and 51 men) of 76 consecutive patients treated between January 1960 and December 1979 with percutaneous pinning, traction, and ambulation in Thomas splints for slipped capital femoral epiphyses (physiolysis colli femoris; PCF) were re-examined radiologically and clinically to evaluate long-term results of an abandoned technique. Median follow-up time was 21 years (range: 8 to 28). The average age at symptom start was 14 years (range: 9 to 17). Fourteen patients were operated bilaterally, while 15 were operated on the right side only and 33 on the left side only. No additional hip surgery for coxarthrosis as adults had been performed. At the clinical examination the mean hip-movement-sum was 220 degrees (range: 30 degrees to 300 degrees). Pain occurred in 31 hips. A limp was found in 23 patients, and 56 had no impairment of working ability. At radiologic examination, 30 patients showed sequelae of PCF, and 30 (48%) had bilateral signs of PCF at follow up.

The frequency of bilateral physiolysis colli femoris was evaluated in 62 patients. At first admission, 5 patients had a bilateral slipping. Further, 9 patients had slipping diagnosed in the contralateral hip during adolescence 1-3 years after the primary operation. At the follow-up examination 22 years after the primary operation, radiographs showed bilateral sequelae of slipping in 30 of 62 patients. Of the nine slips diagnosed later during adolescence, one showed mild and two severe arthrosis. Among the 16 slips diagnosed at follow-up, mild arthrosis was found in four hips. We recommend bilateral pinning at first admission in all patients with a slipped capital femoral epiphysis.

The object of the investigation is to illustrate the results and complications following Partridge's osteosynthesis of proximal fractures in the neighbourhood of the prosthesis. During a period of 40 months, eight consecutive patients (two men and six women) with proximal fractures of the femur in the neighbourhood of a hip prosthesis were subjected to osteosynthesis by Partridge's method. All of the fractures resulted from low energy trauma. The average age was 72 years (51-84) and the average duration of observation was 2.3 years. Weight-bearing was permitted after an average of 14.5 weeks and the radiographically assessed healing time was 16 weeks on an average. In all of the patients, cortical erosion developed under the Partridge bands 10-16 weeks postoperatively. In five patients, the initial erosions were of limited extent and were stationary during the period of observation. In three patients, the osteolysis was progressive and reoperation with introduction of a long-shafted femur prosthesis proved necessary. In addition, homologous boney transplants were necessary in two of these patients. Stability and healing of the fracture are obtained by osteosynthesis by Partridge's method but, on account of the osteolysis which is frequently pronounced and progressive, the patients should be followed-up meticulously in view of the possibility of removal of the Partridge material and possible replacement by a long-shafted femur prosthesis before the bone is completely eroded.

In a series of 10 patients with traumatic dislocation of the knee joint, closed reduction could be accomplished in nine. Conservative treatment was employed in four and operative repair of the ligaments and capsule in six patients. In two of three patients with complicating artery injury, vascular repair was successful. Above-knee amputation was performed in one patient because of delay in the diagnosis of vascular injury and in another patient because of arteriosclerotic gangrene. At follow-up examination, on average 6 years after the accident, the stability and motion of the knee were evaluated as good in five patients (three operated), fair in two (one operated) and as poor in one operated patient. The conclusions are that good knee function can thus be achieved with both conservative and operative treatment, and that limb salvage depends on prompt diagnosis and treatment of vascular complications.

Compression of the median nerve and the nerve due to the anatomical anomaly processus supracondyloidea humeri is a rare condition. A case of combined median and ulnar nerve compression is described. Diagnostics and treatment are discussed in the light of the present case history and those described in the literature. The conclusion is that the treatment should be superiosteal resection of the process together with the origin of the pronator teres muscle.

The purpose of this investigation was to test the hypothesis submitted by Osborne (1957), which proposed that the symptoms of compression ulnar neuritis, in most cases, result from compression on the ulnar nerve at the proximal border of the aponeurosis of the flexor carpi ulnaris muscle. Thirty-two simple decompression operations were performed on 31 patients, diagnosed as suffering from compression neuritis of the ulnar nerve. They were subsequently examined over a period of 5 years. Relief from symptoms was achieved in 28 cases, whilst four patients derived no improvement from the operation. Three of the four unsuccessful cases were judged to have been incorrectly diagnosed and were not suffering from compression of the ulnar nerve in the elbow. A second operation was required in two patients, in one a second decompression and in the other anteposition. No surgical or post-surgical complications occurred.

In a prospective study of 220 displaced femoral neck fractures treated with a sliding-screw-plate, the cases were allocated to osteosynthesis with or without compression. In surviving patients followed for at least 1 year, union occurred in 57/85 with compression and 58/71 without compression. At 2 years, necrosis was radiographically evident in 9/37 and 7/36 united fractures. Thus, compression cannot be recommended when displaced femoral neck fractures are treated with a sliding-screw-plate.

In a consecutive study of 588 knee arthroscopies, the accuracy of the clinical and arthroscopical diagnosis is evaluated by means of the diagnostic specificity and sensitivity. The investigation includes a number of orthopaedic knee disorders, and it is shown that arthroscopy gives a substantial increase in the diagnostic accuracy. Follow-up examination of the non operated patients showed that surgery was avoided in 19 per cent of the patients, in whom surgery was indicated by clinical diagnosis. It is concluded that arthroscopy is a safe and valuable procedure in the diagnosis of knee disorders, and the best method to avoid unnecessary surgery.

Thirteen cases of traumatic anterior and posterior hip dislocations in children were treated during a period of 25 years. All of them were available for follow up from 5 to 26 years postinjury. Twelve of the patients had their dislocation reduced within six hours after the injury. None of them developed any complication, and the range of movement was the same as in the noninjured hip. One patient, who had his hip reduced 37 hours after the injury, experienced pain due to osteoarthritis 7 years after the injury at the age of 21 years.

To elucidate the factors important for development of avascular necrosis of the femoral head following traumatic posterior dislocation of the hip, 98 adult patients with 100 hip dislocations were reviewed after a minimum follow-up of 5 years. Avascular necrosis of the femoral head was found in only 4.8% of the hips reduced within 6 h, but in 52.9% of the hips reduced more than 6 h after the injury. Dislocations were classified according to Stewart and Milford [11]; a significantly higher incidence of avascular necrosis was found in grade-III and -IV dislocations than in grade-I and -II dislocations. We could not demonstrate any benefit from skeletal traction or non-weight bearing. The age of the patients was of no importance.

To determine the prognosis and best treatment for patients who have a posterior dislocation of the hip associated with a fracture of the femoral head or neck (Grade IV, according to the classification of Stewart and Milford), we surveyed the records of 201 patients who had been treated for 203 posterior dislocations from 1958 to 1985 and selected the cases of 19 patients (19 posterior fracture-dislocations of the hip) for further review. Each of the injuries had resulted from a motor-vehicle accident. Thirteen patients had had a posterior dislocation with an associated fracture of the femoral head located either caudad or cephalad to the fovea centralis (Pipkin Type-I or Type-II injury), one had had a posterior dislocation with associated fractures of the femoral head and neck (Pipkin Type III), two had had a posterior dislocation with associated fractures of the femoral head and the acetabular rim (Pipkin Type IV), and three had had a fracture-dislocation that we could not categorize according to the Pipkin classification. Twelve patients had been treated by closed reduction for a Type-I or Type-II injury; one, by open reduction after an unsuccessful closed reduction for a Type-I injury; one, by primary total hip replacement for a Type-III injury; and three, by open reduction with screw fixation of the acetabular fracture and removal of the fragment of the head for two Type-IV injuries and one unclassified injury. An additional two patients had had both a fracture of the femoral neck and a dislocation; one hip was treated primarily with a Moore prosthesis and the other was left unreduced.(ABSTRACT TRUNCATED AT 250 WORDS)

A series of 24 consecutive patients with osteomyelitis of the tibia and soft tissue defects were treated according to the principle of radical excision of the infected bone together with transposition of muscle flaps and primary skin cover as a one-stage procedure. External fixation was used for stabilization of bone. The mean duration of osteomyelitis before radical operation was 72 weeks and the previous stay in hospital averaged 15 weeks. Twenty-one patients had previously undergone 3.7 operations because of the infection. Staphylococcus aureus was cultured in 50% of the patients, while no bacteria could be identified in six patients. Appropriate antibiotics were given for an average of eight weeks. In four patients a secondary bone transplant and in three patients another skin transplant was necessary. One patient refusing further reconstructive surgery insisted on an above-knee amputation because of persisting infection. After an average observation time of 2 1/2 years no infection or instability of the tibia could be demonstrated, but one patient showed two small skin defects. These results indicate that radical excision of infected bone in combination with muscle transposition and primary skin cover is effective in the treatment of posttraumatic osteomyelitis of the tibia.

Calcaneal fractures in young children are seen very infrequently. Intraarticular calcaneal fractures in children under the age of ten years make up 8-39% of the calcaneal fractures in that age group, and most often non or only a slight displacement is seen. The diagnosis can be delayed because of unclear symptomatology. Generally the treatment is conservative and the prognosis very good. Two cases of severely displaced intraarticular calcaneal fractures in children aged six and ten years are presented together with a survey of the literature.

One hundred and twenty-seven hips in 125 adults were treated for traumatic posterior dislocation during a period of two decades. Ninety-eight patients (100 hips) were available for follow-up examination at a minimum of five years (average, fourteen years) after injury. By both clinical and radiographic criteria eighty hips (80 per cent) had an excellent or good result. Forty-two per cent of the hips that were reduced more than six hours after the dislocation had an excellent or good result and 88 per cent of those that were reduced within six hours after dislocation had an excellent or good result. Thirty-one per cent of the hips with a Grade-III dislocation had an excellent or good result, as compared with 90 per cent of those with a Grade-I dislocation. Twenty-two per cent of the hips with an excellent or good result had avascular necrosis of the femoral head. We found the time-interval between injury and reduction, the severity of the initial injury, and the development of avascular necrosis of the femoral head to be the most important factors with regard to the long-term prognosis. Avascular necrosis occurred most frequently in hips that underwent reduction after a delay of more than six hours.