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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.