Walking ability following knee arthroplasty: a prospective pilot study of factors affecting the maximal walking distance in 18 patients before and 6 months after total knee arthroplasty.

Functional assessment of patients before and after prosthetic knee arthroplasty is based on clinical examination, which is usually summarized in various knee scores. The present study proposes a different and more subject orientated assessment for functional grading of these patients by measuring their maximal distance of walking ability, which is not apparent from the conventional outcome scores. Eighteen consecutive patients with knee osteoarthritis were evaluated for their knee and knee functional scores (The Knee Society clinical rating system) and for the maximal distance of their walking ability before and 6 months after knee arthroplasty. Specially designed walking ability grading was used for evaluation of walking on walkway. The pre- and post-operative knee scores and maximal walking distance and grading were statistically compared. A significant improvement in the knee and functional scores following surgery was observed. But the maximal walking ability grades and distances did not change significantly following surgery, showing a high relation between pre- and post-operative values. The limitation in post-operative walking was due to the revealed additional health disabilities, not related to the affected knee. Therefore we suggest that pre-operative evaluation of walking abilities should be taken into consideration both for patients' selection and timing of surgery and also for matching of patients' expectation from outcome of prosthetic knee arthroplasty.

Nuclear magnetic resonance proton imaging of bone pathology.

Thirty-two patients with diversified pathology were examined with a supraconductive NMR imager using spin echo with different TR and TE to obtain T1 and T2 weighted images. They included 20 tumors (12 primary, eight metastasis), six osteomyelitis, three fractures, two osteonecrosis, and one diffuse metabolic (Gaucher) disease. In all cases except for the stress fractures, the bone pathology was clearly visualized in spite of the normal lack of signal from the compact cortical bone. Nuclear magnetic resonance (NMR) imaging proved to be at least as sensitive as radionuclide scintigraphy but much more accurate than all other imaging procedures including computed tomography (CT) and angiography to assess the extension of the lesions, especially in tumors extended to soft tissue. This is due both to easy acquisition of sagittal and coronal sections and to different patterns of pathologic modifications of T1 and T2 which are beginning to be defined. It is hoped that more experience in clinical use of these patterns will help to discriminate between tumor extension and soft-tissue edema. We conclude that while radionuclide scintigraphy will probably remain the most sensitive and easy to perform screening test for bone pathology, NMR imaging, among noninvasive diagnostic procedures, appears to be at least as specific as CT. In addition, where the extension of the lesions is concerned, NMR imaging is much more informative than CT. In pathology of the spine, the easy visualization of the spinal cord should decrease the need for myelography.

Left ventricular contractility and function at peak aerobic and anaerobic exercises.

PURPOSE: The present study compared and evaluated left ventricular function and contractility at peak incremental aerobic type exercise and all-out explosive anaerobic effort in young healthy trained subjects. METHODS: Twenty-two young healthy trained subjects (19 +/- 1 yr) were studied by two-dimensional direct M-mode echocardiography at peak aerobic and at peak all-out anaerobic exercises, performed on cycle ergometer. RESULTS: All subjects completed the study without any electrocardiographic abnormalities. Significant (P < 0.05) differences between the aerobic and the anaerobic efforts were noted for peak cardiac output (24 +/- 2.0 and 15.0 +/- 1.1 L x min (-1), respectively), left ventricular pressure-volume ratio (5.8 +/- 0.6 and 4.7 +/- 0.5 respectively), end systolic volume (33 +/- 4 and 42 +/- 5 mL, respectively), ejection fraction (79 +/- 7 and 66 +/- 5%, respectively), and total peripheral resistance (TPR) (367 +/- 90 and 704 +/- 90 dynes x s(-1) x cm(- 5), respectively). CONCLUSIONS: These data suggest that left ventricular at peak all out anaerobic effort differed markedly from those observed at peak aerobic exercise. These differences are presumably due to the different after-load responses between the two exercise modes. Therefore, it is suggested that anaerobic-type effort should be performed with great caution in normal young healthy subjects.

Patellar dislocation following total knee replacement.

The reported incidence of patellar problems after total knee replacement has ranged from 5 to 30 per cent. Patellar dislocation is infrequent but can cause disabling symptoms. Between January 1974 and May 1982, eleven patients (twelve knees) with symptomatic lateral dislocation of the patella after total knee replacement were treated at The Hospital for Special Surgery by realignment of the extensor mechanism. All of the patients were women. Their average age was sixty-two years and average weight, eighty-seven kilograms. The diagnosis was osteoarthritis in seven knees and rheumatoid arthritis in five. Most of the patients had had preoperative valgus deformity (average, 18 degrees). The cause of dislocation was trauma in three knees, incorrect tracking of the patella after replacement in six, and malrotation of the tibial component in three. Four different prosthetic designs had been used. The design of the implant did not appear to be a factor causing dislocation in this group. The patellar dislocation was treated by proximal realignment of the quadriceps in ten knees, lateral retinacular release alone in one, and revision of the tibial and femoral components combined with proximal realignment in one. After an average follow-up of thirty-four months (range, twenty-four to fifty-seven months), the results according to The Hospital for Special Surgery knee-rating scale were excellent in ten knees and good in two, and there had been no redislocations.

Successive bilateral total knee replacement.

We studied the results of 304 posterior stabilized condylar knee arthroplasties, performed over a two and a half-year period, to compare unilateral, bilateral one-stage, and bilateral staged arthroplasty. The minimum length of clinical follow-up was two years. Using The Hospital for Special Surgery rating system, we found the clinical results to be identical for all three groups. The medical complications were similar in each group except that there was a higher incidence of thromboembolism and pulmonary embolism, as seen venographically, in the patients with staged procedures. We concluded that one-stage bilateral knee arthroplasty is preferable in a patient who requires replacement for severely arthritic knees.

Anxiety reaction in children during removal of their plaster cast with a saw.

We have had experience of an 18-month-old boy with a cardiomyopathy who died a few minutes after removal of his cast with a saw, apparently from a malignant cardiac arrhythmia triggered by anxiety. We therefore examined the anxiety reaction to this method of removal of a plaster cast in 20 healthy children; ten were provided with hearing protectors and ten were not. The level of anxiety was assessed by measuring the heart rate, a known physiological indicator of anxiety, before, during and five minutes after removal of the cast. The noise level was also measured. The results showed a mean increase in heart rate during the procedure of 27.9 beats per minute (bpm) (26.9%) in the children with no hearing protectors and 10.4 bpm (11.1%) in children who used hearing protectors (p < 0.001). Five minutes after the procedure the heart rate had returned to the baseline rate in all patients. We recommend that hearing protectors should be used in children undergoing removal of a plaster cast to decrease the anxiety reaction. If possible, clinicians should avoid the use of a saw for this purpose in children with a cardiomyopathy.

Anatomy of the normal knee as seen by magnetic resonance imaging.

Nuclear magnetic resonance imaging (MRI) was used to study the normal knee. As well as revealing bone quality, MRI provided useful information on intra-articular and extra-articular soft tissues. Midsagittal views gave clear images of the cruciate ligaments, and of the patellar and quadriceps tendons. Parasagittal views were the best for delineating the menisci which, like ligaments and tendons, are of low intensity; the semimembranosus tendon and its insertion to the proximal tibia were also seen clearly in these views. The cruciate ligaments and menisci, though visible in the coronal view also, were better seen in the sagittal view. Axial views provided information on the structure of the patella, its cartilage, the patellofemoral joint and posterior soft-tissue structures.

Weight-bearing patterns on the knees of preterm infants.

In this study we present a method of monitoring the forces under the knees of preterm infants lying in the prone position. Dual force sensing resistor transducers, connected to optically-isolated amplifiers, were used to monitor the forces. A thermistor airflow sensor was used for the parallel monitoring of the respiratory signal. The measurements were made on ten preterm infants. The average forces were 0.51 and 0.50 N for the left and right knees, respectively. In the frequency domain, the basic harmonic of the force traces was 1.27 Hz approximately, corresponding to the respiratory rhythm. Additional, smaller harmonics, were detected in the force traces at 2.54 and 3.81 Hz. A rather notable power signal could also be seen around 0.1 Hz. The results obtained indicate that the system developed is highly sensitive for providing data on the amplitudes, periods and sequences of oscillations and symmetry of load bearing in preterm infants. Knowledge of the normal and abnormal reaction force patterns may assist in the early diagnosis of abnormal neurodevelopment.

[Laser therapy in the prevention and treatment of mucositis caused by anticancer chemotherapy]. / La laserthérapie dans la prévention et le traitement des mucites liées à la chimiothérapie anticancéreuse.

The appearance of mucositis is a frequent and painful secondary effect of anticancer chemotherapy. Patients who develop oral toxicity during the first course of treatment will almost assuredly show identical side effects during each subsequent course unless the drugs are changed or the doses are lowered. In the absence of an efficacious antidote or preventive prophylaxis for such lesions to date, this report presents the results of a preliminary retrospective non-randomized study of the effect of soft-laser treatments on mucositis in cancer patients receiving combination chemotherapy, including 5-fluorouracil. Iatrogenic mucositis was observed during 43% of 53 chemotherapy cycles in the case control population. Curative laser therapy reduced the time to repair lesions and the rate of therapeutic modifications. For patients who received soft-laser therapy as a preventive measure, the incidence of oral complications was reduced to 6% during 101 cycles of chemotherapy. All of these patients, even those who have encountered mucositis before receiving preventive laser therapy, terminated their cancer therapy as originally scheduled. Well designed and carefully controlled trials will be necessary to define the place of helium-neon laser therapy in the repair and prevention of oral complications due to cancer chemotherapy.

Osteoid osteoma: resection with CT guidance.

BACKGROUND: Osteoid osteoma is a benign bone lesion characterized by nocturnal pain mostly, which may be relieved by non-steroidal prostaglandin inhibitors. Treatment by complete resection of the nidus immediately relieves the pain. Intraoperative location of the nidus may be difficult, and extensive bone resection may be necessary to ensure complete excision. Few studies have described resection of osteoid osteoma under CT guidance, and little attention has been given to lesions near the neurovascular bundle. OBJECTIVE: To report our results of osteoid osteoma resection under CT guidance, with specific attention to lesions lying near the neural structure. METHODS: Nine patients with suspected osteoid osteoma underwent resection with a 6.8 mm core drill under CT guidance. RESULTS: Histologic confirmation was obtained in seven patients, while in two there was no evidence of the nidus in the excised bone material. All nine reported complete pain relief immediately after the surgery. Postoperative CT scan showed complete removal of the osteoid osteoma. CONCLUSIONS: Removal of osteoid osteoma under CT guidance is simple, safe and allows complete removal of the nidus with low morbidity.

Early mobilization after sliding achilles tendon lengthening in children with spastic cerebral palsy.

Equinus deformity is a common finding in children with cerebral palsy and may be treated by Achilles tendon lengthening. To prevent recurrence, some authors recommend immobilizing the operated leg with an above-knee cast for six weeks, followed by use of a night splint or orthosis. Nevertheless, there are recurrence rates of up to 20.5%. The aim of this study was to evaluate the long-term result of postoperative immobilization for two weeks in a below-knee cast and early weight bearing, without the use of a splint or orthosis. Thirty-six children (52 feet) with spastic cerebral palsy underwent sliding Achilles tendon lengthening. Follow-up of five to ten years showed a comparable recurrence rate (19.2%) to that reported with the standard, more stringent management approach. Most of the recurrences were in children operated on before five years of age. We believe earlier motion helps to sustain the tendon length achieved at surgery and allows for earlier independent gait.

Involvement of the foot and ankle in patients with Gaucher disease.

Of 48 children with type I Gaucher disease treated at our hospital, 11 had involvement of the foot and ankle that first appeared in adolescence. Follow-up ranged from 3 to 27 years (average, 10 years). We reviewed their clinical and radiographic histories. Patients presented with four types of pain: six (7 events of pain) complained of dull pain defined as nonspecific; seven (11 events) had severe pain caused by bone crisis; two (2 events) had moderate progressive pain caused by pathological fractures; and one had painful swollen ankles caused by degenerative arthritis. Greater awareness of these complications in patients with Gaucher disease will prevent misdiagnosis and lead to early treatment.

Arthrodesis with the Ilizarov device after failed knee arthroplasty.

Thirteen patients with failed total knee arthroplasty (TKA) due to infection (12 patients) or aseptic loosening (1 patient) underwent arthrodesis using the Ilizarov external fixator. Solid fusion was achieved in all patients with an average healing time of 27.6 weeks. Patients spent an average 18.8 weeks in the fixator followed by an average 8.8 weeks in a plaster cylinder cast. Five patients had a pin tract infection and one a superficial wound infection. One patient had 15 degrees recurvatum after surgery that was gradually corrected by adding a hinge system to the fixator. Average shortening of the affected limb was 3.7 cm (range: 1-6 cm). The Ilizarov fixator for knee arthrodesis after failed TKA produced favorable results and should be considered for use by surgeons familiar with the technique.

[Surgery for groin and lower abdominal pain in soccer players].

We treated 57 professional soccer players with groin and lower abdominal pain, 44 of them successfully, using conservative methods and 13 by surgery. Because of its anatomical site, the gracilis muscle is involved in almost all movements of the femur. It therefore is frequently involved in injury due to overuse, especially at its insertion (enthesopathy). In all 13 operated on, the gracilis was cut percutaneously, sometimes as a single procedure and sometimes with concomitant sportsmen's inguinal hernioplasty. All except 1 of those operated on returned to their professional sport activities.

[Screening for scoliosis in western Galilee schools].

Scoliosis screening is still under debate. It is generally agreed that it is not cost-effective, but some still favor it as integral to preventive medicine. Among 2940 school children, aged 9 - 13, from several Moslem-Arab villages in the western Galilee, 55 (1.9%) were found to have some deformity on physical examination and were referred for spinal X-ray. Of these, 24 were X-rayed and in 20 of them there was a scoliosis of more than 7 degrees. The prevalence of in-family marriage in those with deformities was 31%, not significantly different from the 35% found in their communities. Using the worst-case analysis, the Moslem-Arab population of western Galilee cannot be regarded as a population at risk for scoliosis. Considering the poor cooperation of the parents with further investigation, we conclude that scoliosis screening should not be performed in this community.

[Operative mortality in surgery for hip fractures].

Prevalence of hip fractures is increasing world-wide, as the mean age of populations increases. Despite advances in anesthesia, nursing care, and surgical techniques, hip fractures remain a significant cause of morbidity and mortality in the elderly. We operated on 65 cases of hip fractures from 1995 to the end of 1997: average age was 82.9, 72% were women, average waiting time for operation was 1.6 days, perioperative mortality was 3.5% and postoperative mortality 26.2%.

[Intramedullary nailing of mid-femoral fractures].

75 consecutive cases of mid-shaft femoral fractures were treated by open intramedullary nailing, using the solid, diamond-shaped Hansen-Street nail. The average age was 32.5 years; road accidents accounted for 43 cases; average operative time was 40 minutes. There were 2 systemic complications but no infections. 56 of the 75 were studied after an average of 5 years and 19 were followed for at least 6 months. At 4 months all fractures were united except 1. Average time to sound bone union was 4 months. There was no residual deformity in varus-valgus or in the sagittal plane. Malrotation was rare and did not exceed 10 degrees. There was shortening of 2 cm in 3 cases of comminuted fractures. All patients followed up returned to regular daily function. The Hansen-Street nail used in an open procedure is an accurate method of anatomic reduction. As opposed to close techniques, we found the procedure to be simple and quick, without undue exposure of the surgical team to radiation and without other complications, such as nerve damage due to traction. This device is indicated for use only in fractures of the middle third of the femoral shaft.

[Stabilization double osteotomy of the knee].

Stabilization osteotomy of the knee is a single or double 1-stage osteotomy done to correct ligamentous deficiency of the knee. The concept of stabilization osteotomy depends on the residual ligamentous and capsular tissues which envelope the circumference of the joint. The technique relies on open wedge osteotomy to restore alignment of the joint. Satisfactory results in 6 patients who underwent stabilization osteotomy as a salvage procedure during the past 5 years encouraged us to publish the principles of this concept.

[Magnuson-Stack operation for chronic anterior shoulder instability].

Between the years 1975-1992 we operated on 30 cases of recurrent anterior dislocation of the shoulder by the Magnuson-Stack procedure, using the subscapularis tendon. 23 patients (25 shoulders) have since been followed for an average of 5 years. We developed a comprehensive shoulder rating scale to evaluate functional status of involved shoulders. By this rating system the results were excellent in 73.9% of the cases, good in 17.4% and fair in 8.7%. The operation is technically simple, rapid, had no complications and is at least as effective as other operations.

The use of the Hansen-Street intramedullary nail in midshaft fractures of the femur.

A retrospective study was conducted on 75 consecutive femoral midshaft fractures treated with intramedullary nailing using the solid-diamond-shape Hansen-Street nail with an open technique. The average age of patients was 32.5 years. Road accidents accounted for 43 cases. The average operative time was 40 minutes. There were two systemic complications. No infection occurred. Fifty-six cases could be gathered for this study, with an average follow-up of 5 years; 19 were followed for at least 6 months. At 4 months, all the fractures were united except one. The average time to sound bony union was 4 months. There was no residual deformity in varus-valgus or in the sagittal plane. Malrotation was rare and did not exceed 5 degrees. Shortening of 2 cm was found in 3 patients where the fracture was comminuted. All followed patients returned to regular daily function. The use of the Hansen-Street nail in an open procedure is an accurate method for anatomic reduction. As opposed to closed techniques, the procedure proved in our hands to be simple and quick, without undue exposure to radiation of the surgical team, and without such other complications as nerve complications due to traction. The procedure with this device is indicated for mid-third fractures of the femoral shaft only.