Reliability and validity of surface EMG assessments combined with isometric muscle strength testing in patients with abdominal rectus diastasis and asymptomatic controls.

PURPOSE: Patients with abdominal rectus diastasis (ARD) may have muscular functional impairments, but clinics lack appropriate objective assessment tools. The aim was to establish the relative and absolute reliability, and convergent validity, of muscular activity using Surface Electromyography (SEMG) during isometric abdominal muscle strength testing in patients with ARD and controls without ARD. METHODS: Twenty-six patients with ARD were matched for age, sex and BMI with controls without ARD. Participants were tested twice during isometric muscular contractions using SEMG located on six abdominal sites. Mean amplitude, fatigue, and recruitment order were analyzed. Relative reliability was evaluated with Intraclass Correlation Coefficients (ICC), while absolute reliability was estimated by calculating the Standard Error of Measurement and Minimal Detectable Change. Convergent validity was addressed in relation to participant characteristics, functional ability, and symptoms. RESULTS: Mean SEMG amplitude for all abdominal wall muscle contractions showed moderate to excellent relative test-retest reliability, with ICC values ranging from 0.46 to 0.97. In contrast, fatigue and recruitment order displayed poor to moderate relative reliability in both groups. Absolute reliability measures were generally high. A moderate to high convergent validity (ARD: rho-value 0.41-0.70; Controls: rho-value 0.41-0.75) was observed for mean amplitude in relation to a functional sit-to-stand test, abdominal circumference, BMI, back pain, and quality-of-life. CONCLUSIONS: The results of applying SEMG during isometric abdominal muscle support practicing the method in clinics, although additional development is needed with further standardization and more functional testing. Furthermore, the method demonstrates construct validity in patients with ARD and in age- and sex-matched controls.

A virtual reality trauma simulator.

The authors have evaluated a trauma simulator based on virtual reality techniques. Ten surgeons and 15 medical students performed distal locking of a femoral nail (A). Furthermore, 10 medical students performed simulated osteosynthesis of a femoral neck fracture (B). Total surgery time (A) (mean value) was shorter for surgeons (108 s) compared with students (157 s) at the first (p = 0.033), second (102 respectively 138 s, p = 0.13) and third (96 respectively 160 s, p = 0.15) operation. Total fluoroscopy time (A) (mean value) was shorter for surgeons compared with students at the first (45 respectively 89 s, p = 0.001), second (48 respectively 83 s, p = 0.02) and third (50 respectively 107 s, p = 0.10) operation. The positioning of the hip nails (B) improved between the first and last trial. Total surgery and fluoroscopy time were reduced. All participants thought that this and similar simulators should be part of the programme and that this simulator would be helpful if they were about to learn the procedures.

Monitoring referral and treatment in soft tissue sarcoma: study based on 1,851 patients from the Scandinavian Sarcoma Group Register.

This report is based on 1.851 adult patients with soft tissue sarcoma (STS) of the extremities or trunk wall diagnosed between 1986 and 1997 and reported from all tertiary referral centers in Norway and Sweden. The median age at diagnosis was 65 years and the male-to-female ratio was 1.1:1. One third of the tumors were subcutaneous, one third deep, intramuscular and one third deep, extramuscular. The median size was 7 (1-35) cm and 75% were high grade (III-IV). Metastases at presentation were diagnosed in 8% of the patients. Two thirds of STS patients were referred before surgery and the referral practices have improved during the study. The preoperative morphologic diagnosis was made with fine-needle aspiration cytology in 81%, core-needle biopsy in 9% and incisional biopsy in 10%. The frequency of amputations has decreased from 15% in 198688 to 9% in 1995-1997. A wide surgical margin was achieved in 77% of subcutaneous and 60% of deep-seated lesions. Overall, 24% of operated STS patients had adjuvant radiotherapy. The use of such therapy at sarcoma centers increased from 20% 1986-88 to 30% in 1995-97. Follow-up has been reported in 96% of the patients. The cumulative local recurrence rate was 0.20 at 5 years and 0.24 at 10 years. The 5-year metastasis-free survival rate was 0.70.

Local recurrence of deep-seated, high-grade, soft tissue sarcoma: 459 patients from the Scandinavian Sarcoma Group Register.

This study was based on 459 adult patients with deep, high-grade, soft tissue sarcoma of extremities or trunk wall reported to the Scandinavian Sarcoma Group Register (1986-1993). All patients had their definitive surgery for primary tumor at a sarcoma center. The median follow-up was 7.5 (3-12) years. 204 patients are still alive. 68 patients had amputations and 391 underwent limb-sparing surgery. Among 183 patients with intralesional or marginal margins after limb-sparing surgery, 65% had postoperative radiotherapy and 9% of the 198 patients with wide margins. The local recurrence rate after limb-sparing surgery was 26%. The rate with an intralesional or marginal margin was 39% without postoperative radiotherapy versus 24% when radiotherapy was given. It was 25% after a wide margin, and no recurrences were noted among the 10 patients with a compartmental surgical margin. Among patients with a wide margin, a subset fulfilling criteria for a myectomy was defined. The local recurrence rate was 26% among these 62 and there was no advantage of myectomy over other wide margins. More radical surgical margins would improve the local recurrence rate, but this can hardly be achieved in center-operated patients without increasing the amputation rate. Instead, increased use of radiotherapy in all patients with inadequate margins, and to a larger extent in those with wide margins will improve local control.

Consequences of local recurrence of soft tissue sarcoma: 205 patients from the Scandinavian Sarcoma Group Register.

From the Scandinavian Sarcoma Group Register, information on 1,224 surgically-treated patients with soft tissue sarcoma (STS) of the extremity or trunk wall, diagnosed between 1987 and 1995, was collected. 205 patients, one third of whom were referred to a center with a local recurrence, had a total of 284 local recurrences. This analysis describes the treatment for these local recurrences, complications and risk of further recurrences. 169 patients were surgically treated for their first local recurrence. An intralesional or marginal margin was achieved in 110 of these patients, 59 of whom were also given radiotherapy. 54 of the 169 patients had a second local recurrence. The second local recurrence rate was 0.50 if the first local recurrence had been treated with only surgery with a marginal margin, compared to 0.28 if treated with surgery with a marginal margin and radiotherapy or with a wide margin (p = 0.0008). In extremity STS, the crude amputation rate for local recurrences was 0.22 (31 of 142)-i.e., higher than for primary tumors 0.09 (96 of 1065) (p < 0.0001). A high local recurrence rate after treatment outside of sarcoma centers has earlier been shown. We conclude that the consequences of local recurrence in terms of morbidity and costs justifies referral of STS patients for multidisciplinary evaluation and multimodality treatment.

Clinical course in synovial sarcoma: a Scandinavian sarcoma group study of 104 patients.

We analyzed treatment and outcome in 104 Scandinavian patients with synovial sarcoma in the extremities or trunk wall, diagnosed between 1986 and 1994. Only surgically treated patients without metastases at diagnosis were included. Median follow-up of survivors was 6 (3-11) years. 34 patients developed metastases. The overall 5- and 7-year survival rates were 0.76 (95% CI 0.66-0.83) and 0.69 (0.58-0.78), respectively. Large tumor size and amputation were significantly associated with impaired metastasis-free survival. Patients with local recurrence had a higher risk of metastases following the local event. Local excision with inadequate margin was associated with a higher risk of local recurrence.

Constant region of a kappa III immunoglobulin light chain as a major AL-amyloid protein.

AL-amyloidoses are generally described as a group of disorders in which N-terminal fragments of monoclonal immunoglobulin light chains are transferred into amyloid fibrils. We have, by amino acid sequence analyses and immunological methods, characterized the Bence-Jones protein and the corresponding AL protein as a kappa III immunoglobulin light chain from material of a patient with systemic AL-amyloidosis presenting as a local inguinal tumour. The two proteins showed some unique features. The major part of the AL amyloid fibril protein consisted of C-terminal fragments of the Bence-Jones protein. Furthermore, both the Bence-Jones protein and the AL protein were glycosylated, with possibly a glycosylation in the constant part of the light chain.

Twenty-year results of McKee-Farrar versus Charnley prosthesis.

The results of 107 consecutive McKee-Farrar and 70 Charnley total hip arthroplasties performed in 169 patients between 1975 and 1976 are reviewed. At an average followup of 20 years (range, 19-21 years), 29 patients with 20 McKee-Farrar and 11 Charnley prostheses were available for clinical and radiologic evaluation; 102 patients (107 hips) had died, 3 patients were lost to followup, and 5 patients (6 hips) were unavailable for review because of medical problems. There were 5 revisions for sepsis and 1 Girdlestone procedure for recurrent dislocation. Sixteen McKee-Farrar and 8 Charnley prostheses were revised for aseptic loosening, giving a 20-year aseptic probability of survival of 77% and 73%, respectively. Radiographic signs of loosening were present in 52% of the surviving prostheses. Clinical scores showed weak correlation with the radiographic loosening in both groups, and 18 McKee-Farrar and 8 Charnley prostheses were still considered satisfactory by the patients. The mean annual linear polyethylene wear was 0.12 mm. Osteolytic lesions were observed in association with 2 McKee-Farrar and 5 Charnley prostheses in surviving hips. The long term results of the McKee-Farrar prosthesis are comparable with those of the low friction arthroplasty in this series. Wear of the polyethylene bearing and accumulation of polyethylene particles in the periprosthetic tissue may become an increasing problem. Second generation all metal implants seem to be worth considering in patients with long life expectancy.

Effect of diclofenac on fixation of hydroxyapatite-coated implants. An experimental study.

We studied the effect of non-steroidal anti-inflammatory drugs on the fixation of hydroxyapatite-coated implants. Cylindrical plugs of pure titanium, coated with hydroxyapatite (HA), were inserted into both femora of 10 adult rabbits, 5 of which received 7 daily doses of 30 mg diclofenac. Three weeks after implantation the interface strengths were measured by the pull-out test. The mean peak force for the diclofenac-treated group was 290 +/- 57 N compared with 369 +/- 37 N for the control group (p < 0.025). We conclude that the inhibitory effect of diclofenac on bone repair is not neutralised by HA-coating of an implant.

Revision of infected hip replacement. Two-stage procedure with a temporary gentamicin spacer.

We revised 5 infected totally-replaced hips in 2 stages. At the first operation a gentamicin-loaded modelled cement spacer was inserted, and the definitive prosthesis was inserted 3-8 weeks later. 9-24 months after the last operation, there was a recurrent infection in 1 case. 2 of the patients could walk in the interval.

Effect of platelet derived growth factor on heterotopic bone formation in rats.

Platelet derived growth factor (PDGF) and induction of newly woven bone growth were studied in rats. PDGF (20 ng/mL) was administered continuously for 2 weeks via micro-osmotic pumps to 6-mm-long pieces of demineralized rat femur inserted into muscle pouches. Each rat had a control piece of demineralized bone inserted into the contralateral gluteal muscle. The samples were collected after 4 weeks, and wet and ash weight were recorded. Fourteen rats were evaluated. There were no differences as regards wet weights. PDGF increased the ash weights.

Total hip replacement comparison between the McKee-Farrar and Charnley prostheses in a 5-year follow-up study.

In a prospective study, 177 patients who underwent total hip replacement by the McKee-Farrar or Charnley techniques were followed up for 5 years with yearly clinical examinations, walking tests, and X-rays. The findings concerning pain, walking ability, and complications were satisfactory and similar to the inventors' own 5-year results. Comparison between the two techniques disclosed no major differences. Over 90% of the patients were free from pain; the infection rate was 3.4% and the loosening rate 6%. A walking test showed marked increase in speed over the first few years and a slight decrease after the third year. Our findings do not support the hypothesis that the metal-on-metal prosthesis is clinically inferior to the metal-on-polyethylene prosthesis.

Loosening 5 years after total hip replacement--a radiological study of the McKee-Farrar and Charnley prostheses.

In a prospective study, 138 patients who underwent total hip replacement by the McKee-Farrar or the Charnley technique were monitored yearly for 5 years by X-ray. Six variables were measured on anteroposterior and lateral projections to describe the position of the prosthesis. Lateral opening greater than 50 degrees and cover of the acetabular cup less than 1.5 cm correlated with an increased cup-loosening rate: 71% (98 of 138) were loose at the 5-year follow-up. However, only about one-third of all cup loosenings in the present series can be explained by nonoptimal position of the prosthesis. No significant difference emerged concerning loosening rate between the McKee-Farrar and the Charnley prostheses.

A device for generation of electromagnetic fields of extremely low frequency.

A new device for generation of electromagnetic fields at extra low frequencies, to be used in fracture treatment, is described. The device involves a coil and a battery powered noise-generator. An alternating magnetic field of 4 X 10(-4) T (4 Gauss) (RMS value) with a frequency range 1-1000 Hz is generated. Results from a controlled randomized study of fresh fractures have shown significant differences (p less than 0.01) between the treated group and the control group. The results are encouraging and motivate further investigations with this method.

Stimulation of fracture healing with electromagnetic fields of extremely low frequency (EMF of ELF).

This randomized, controlled study was performed to evaluate how electromagnetic fields affect the accumulation of 99mTechnetium - methylendiphosphonate (Tc-MDP) in fresh fractures. Thirty women with Colles' fractures, aged 50-70 years, participated in this study--some in a control group and some in a treated group. After reduction, all patients were immobilized for four weeks. After randomization, 15 patients were treated by electromagnetic fields of extremely low frequency (EMF of ELF ), which were generated by a coil and a battery-powered portable current generator during the time of immobilization. The frequency of the alternating magnetic field was 1-1000 Hz; the magnitude was 4 gauss [RMS (root-mean-square) value]. The scintigrams were performed one, two, four, and eight weeks after the injury. The activity ratio in the fracture area was significantly higher at the examination of one and two weeks (p less than 0.05, p less than 0.01) in the treated group than it was in the control group. The clinical relevance of the results is not known, but one interpretation of the data is that the stimulation with EMF of ELF improves (accelerates) the early phase of fracture healing. The data warrant further investigation of fresh fracture treatment with this method.

Serial bone scanning of Colles fracture.

Serial bone scannings with 99-M-Tc-MDP have been performed in 15 patients with an extra-articular dorsal-angulated fracture of the distal radius (Colles' fracture). A method for the quantification of healing activity is described. The activity-ratios show a typical pattern of progress during the healing period. There is a correlation between fractures with high activity ratios late in the healing period and fractures that redisplace during the healing period.