The contralateral hip in patients primarily treated for unilateral slipped upper femoral epiphysis. Long-term follow-up of 61 hips.

We reviewed, at an average age of 46 years, a series of 61 patients treated for unilateral slipped upper femoral epiphysis. At maturity there had been slipping of the contralateral hip in 11 patients (18%) and another 14 (23%) had originally had evidence of bilateral slipping when the primary radiographs were reviewed. In only two of these 25 patients (8%) was the slipping of the contralateral hip symptomatic. The incidence of early osteoarthritis of the contralateral hip was 7 of 36 with no slip, 5 of 16 with an untreated slip and 1 of 9 with a slip pinned in situ. If all 61 contralateral hips had been prophylactically pinned at the primary admission, 36 of the operations (59%) would have been unnecessary. We recommend that prophylactic pinning of the contralateral hip should not be standard, but that lateral radiography by the Billing technique be repeated every third to fourth month until closure of the growth plate begins. Hips in which a slip occurs should be pinned in situ.

Long-term results after nailing in situ of slipped upper femoral epiphysis. A 30-year follow-up of 59 hips.

We reviewed the radiological and clinical long-term results after the nailing in situ of slipped upper femoral epiphysis in 59 hips in 43 patients. The displacement of the epiphysis had been measured as the 'slipping angle' before operation and related to the results at follow-up at a mean of 30.9 years (27 to 34). The mean age at follow-up was 44.2 years (39 to 50). Radiographic re-examination of 41 hips with slipping angles of < or =30 degrees at the time of operation showed that eight (20%) had developed mild osteoarthritis and one had severe changes. For 18 hips with slipping angles ranging from 31 to 50 degrees at surgery six (33%) had mild osteoarthritis and three had severe changes. The differences did not quite achieve statistical significance (p = 0.09). Clinical re-examination of the 41 hips with slipping angles of < or =30 degrees showed fair or poor results (Harris hip score <90) in three (7%). In the 18 hips with slipping of 31 to 50 degrees, four had fair or poor results (22%) (p = 0.13). We conclude that nailing in situ for slipping of < or =30 degrees, using one thin nail, can give excellent long-term results. At present we recommend that hips with slips ranging from 31 to 50 degrees should also be nailed in situ, but further long-term studies are required, especially on the choice between nailing in situ and corrective osteotomy for slips in excess of 50 degrees.

Liquid silicone as a lunate prosthesis.

Eleven patients with lunatomalacia were treated by excision of the lunate and instillation of liquid silicone. The silicone vulcanised and formed an in-situ molded prosthesis. The patients were reexamined after a mean of 7.1 years. Four patients were pain-free and two had pain only at work; three had not been improved by the operation and two had undergone arthrodesis. The patients with good results all belonged to group IV pre-operatively. Surprisingly, no patient showed any sign of silicone synovitis, although all the prostheses except one had either fractured or deformed. The reasons for this are discussed and the indications for the operation established.

Loss of hip motion in slipped capital femoral epiphysis: a calculation from the slipping angle and the slope.

The range of hip motion in 128 hips of 108 patients was measured at an average of 32.7 years after slipping of the capital femoral epiphysis (SCFE). Only hips without signs of osteoarthrosis were selected for the study. The hips were divided into three groups depending on treatment (i.e., fixation in situ, no treatment, osteotomy) and compared with those of a group with no slipping (normal hip). The slipping angle (SA) between the basis of the epiphysis and the perpendicular to the anteversion plane on lateral radiographs and the slope (S) between the basis of the epiphysis and the perpendicular to the axis of the femur on anteroposterior (AP) radiographs were measured. The only significant loss of hip motion evident in comparison of normal hips and hips with previous SCFE, was loss of external rotation in hips treated with osteotomy. Hips with no treatment and hips treated with fixation in situ showed no significant loss of hip motion as compared with normal hips. The greatest loss of hip motion in hips treated with fixation in situ was loss of internal rotation (LIR), which can be calculated using the radiographs as sin LIR = sin SA * sin S. The average difference between clinically established and calculated LIR was 1.15 degrees. We conclude that the loss of hip motion after SCFE is slight and in most patients not clinically relevant. Therefore, early surgical intervention, e.g., femoral osteotomy, due to expected loss of hip motion cannot be justified.

Bilaterality in slipped capital femoral epiphysis: importance of a reliable radiographic method.

One hundred patients treated for slipped capital femoral epiphysis (SCFE) were reviewed to evaluate the incidence of bilateral slipping of the epiphysis at an average follow-up time of 32 years. When the patients were examined during adolescence, repeat lateral radiographs of the hips had been obtained by the frog lateral view in 33 patients and by the standardized lateral view according to the method of Billing in 67 patients. At re-examination, 59 patients (59%) were judged to have had a previous bilateral SCFE; in 42 of these 59 patients (71%), slipping of the contralateral hip was asymptomatic. In 23 patients (23%), the diagnosis of bilateral slipping was established at primary admission, in 18 (18%) later during adolescence, and in 18 (18%) not until the patients were reexamined as adults and the primary radiographs were reviewed. The incidence of bilateral slipping was higher in patients in whom the Billing standardized lateral view was used (63%) than in patients in whom the frog lateral view was used (52%). We conclude that the incidence of bilateral slipping of the epiphysis in patients with SCFE is approximately 60% in Sweden. If repeat radiographs of the contralateral hip are obtained with the Billing standardized lateral view until physeal closure occurs, even minor slipping of the epiphysis, which is often advisable to treat, will be apparent.

Treatment of non-union after tibial shaft fracture with a full cortical thickness inlay bone graft.

Twenty-seven non-infected delayed union or non-union fractures of the shaft of the tibia in 26 patients were operated on with a full cortical thickness inlay graft taken from the injured leg. The initial trauma was moderate in 9 fractures and severe in 18. Fifteen fractures were closed injuries and 12 open. The fracture pattern was longitudinal in 5 cases, transverse in 11 and communited in 11. Surgery was performed 12 to 72 weeks (mean: 30 weeks) after the fractures had been sustained. All fractures healed after the bone grafting procedure. The time until union was established after surgery ranged from 6 to 37 weeks (mean: 17 weeks). The healing time was neither influenced by the initial type of fracture pattern (p > 0.05) nor by the fracture age at surgery (r = -0.21). Of 13 patients re-examined 8 to 16 years after surgery, the clinical results were classified as excellent in 8, as fair in 2, and as poor in 3 patients.

Outcome after transphyseal hip fractures. 4 children followed 34-48 years.

We report long-term outcomes in 4 patients with transphyseal fractures of the hip, a rare injury. All the patients were treated without surgery. The results were good in all the patients at follow-up, 34-48 years after injury. The only complication we found was a leg-length discrepancy of 3 cm in 1 patient due to premature closure of the capital femoral physis.

Preoperative skin traction in patients with hip fractures is not useful.

One hundred twenty patients with cervical or trochanteric hip fractures were allocated randomly to groups receiving either skin traction or no special treatment while awaiting surgery. No differences were found between the groups in terms of pain experienced, the need for supplementary analgesics, or complications during the hospital stay. In addition, the repositioning and percentage of united fractures after 4 months did not differ significantly between the groups. The application of skin traction offered no benefits, and thus routine use of preoperative skin traction in patients with hip fractures is not recommended.

The incidence of physiolysis of the hip: a population-based study of 175 patients.

We studied the epidemiology of physiolysis of the hip (or slipped capital femoral epiphysis) between 1946 and 1992 in 175 patients from a well-defined population. The incidence of physiolysis of the hip was calculated using the attack rate method, i.e., the sum of the annual incidences in each 1-year group. The risk of developing physiolysis was 1:998 for boys, 1:1756 for girls and 1:1267 for both sexes and did not change significantly during this period. The average age at diagnosis was 13.6 (7-17) years in boys and 12.1 (8-15) years in girls and did not change to a significant degree during this period. The difference in the boy:girl ratio (1.8:1) and in the preponderance of the left hip being affected first (64% for boys and 52% for girls) did not change significantly during this period. No significant monthly variation was found in the onset of symptoms of physiolysis of the hip.

Does a single device prevent further slipping of the epiphysis in children with slipped capital femoral epiphysis?

All 170 patients (212 hips) treated between 1946 and 1992 for slipped capital femoral epiphysis (SCFE) with fixation in situ with a single device were reviewed to evaluate the incidence of further slipping of the epiphysis after primary treatment. In 154 hips, a smooth device without anchorage in the epiphysis was used and in 58, a device anchored in the epiphysis. In 3 hips, further slipping of the epiphysis occurred after primary treatment with no obvious cause. In 10 hips, an obvious cause for further slipping of the epiphysis was found. These 10 hips were re-operated due to the loss of epiphyseal grip in 6 hips, unsatisfactory placement of the device in 1, while in the remaining 3 hips, the device was removed before physeal closure. Twenty-six hips (12.3%) were re-operated because the device had lost its epiphyseal grip before physeal closure, and in 25 of these hips the device was smooth and had no anchorage in the epiphysis. The conclusion of this study is that a single device with anchorage in the epiphysis is stable enough to prevent further slipping of the epiphysis in hips with SCFE.

Long-term results after surgical management of partial Achilles tendon ruptures.

Although Achilles tendon injuries are common overuse injuries in sports, the exact incidence is unknown, primarily as a result of varying definitions and diagnoses of the underlying pathological changes. Despite numerous studies of treatment of the Achilles tendon injuries, the long-term results are not well known. The results after surgical treatment of chronic partial Achilles tendon ruptures in 64 patients with a follow-up of 6 (1.5-11) years were evaluated in a retrospective study. The ruptures were divided into three groups: (I) proximal (more than 3 cm above the calcaneus), (II) distal and (III) combined (proximal and distal). All patients underwent an operation involving the excision of the devitalized tendon tissue and, in groups (II) and (III), also the excision of the deep Achilles bursa and removal of the dorsal corner of the calcaneus. The functional results were satisfactory in 43 (67%) patients and unsatisfactory in 21 (33%). The results were better in patients with proximal ruptures than in patients with either distal or combined ruptures. Males experienced better results than females. Post-operative immobilization in a plaster cast had no significant influence on the final result. Nine (14%) patients with either a distal or a combined rupture were re-operated on and in seven of them the final result was satisfactory. The conclusion of this study is that partial Achilles tendon ruptures are often difficult to treat and only two out of three patients can be expected to obtain satisfactory results after surgical treatment.

Radiographic assessment of coxarthrosis following slipped capital femoral epiphysis. A 32-year follow-up study of 151 hips.

In all, 108 patients (151 hips) previously treated for slipped capital femoral epiphysis (SCFE), were evaluated radiographically for assessment of coxarthrosis at an average age of 47 years. Five projections were obtained of each hip (supine a.p., supine modified frog lateral, standing a.p., standing anterolateral oblique, and standing posterolateral oblique) and the superior, anterior, and posterior joint space heights were measured (abnormal: superior < or = 3.0 mm and/or anterior and/or posterior < or = 2.5 mm). Sixty-three hips (42%) had joint space narrowing in at least one projection. The standing a.p. and 2 lateral oblique views identified 54 hips as abnormal, and the supine a.p. and modified frog lateral views uncovered an additional 9. The supine a.p. view was the least helpful; 12 abnormal hips on the standing a.p. view were normal on the supine a.p. view. Isolated narrowing in the anterior and/or posterior joint space was found in 9 hips (6%). These changes could only be assessed by the 2 lateral oblique views. Our results illustrate that a combination of standing radiographs, visualising the circumference of the articular space of the hip joint, and modified frog lateral projections is necessary to fully identify coxarthrosis in hips previously treated for SCFE.

Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients.

Of 53 patients with unilateral, displaced and closed or grade 1 open tibial shaft fractures, 27 patients (group I) were randomized to treatment with an intramedullary nail and 26 patients (group II) to treatment with a plaster cast. 12 fractures in the latter group were considered stable enough for treatment with only a cast (group IIa), while 14 fractures in group II showed redisplacement during reduction under anesthesia or at 1 week follow-up. Therefore, these fractures were stabilized with cerclage or screws (group IIb), which was a prerequisite for continuing cast treatment. The mean time-to-union was 19 weeks for group I, and 25 weeks for group II. 6 patients in group I and 16 in group II had delayed union. The Nottingham Health Profile index scores on physical mobility, social isolation, work ability, and sexual life were significantly better in group I than in group II at 3 months after injury. Delayed union, malunion, and restricted range of motion at the ankle joint were common complications when these fractures were treated with a cast. We recommend intramedullary nailing for these fractures.

Functional outcome of anterior cruciate ligament reconstruction in recreational and competitive athletes.

The aim of this study was to compare the outcome after anterior cruciate ligament reconstruction in recreational and competitive athletes, with a minimum follow-up of two years. Forty-nine patients (24 males and 25 females) who, at the time of the index injury, were classified as recreational athletes (Tegner level 2-5) were compared with 226 patients (61 females and 165 males) who, at the time of the index injury, were classified as competitive athletes (Tegner level 9-10). At the follow-up, no significant differences were found between the study groups in terms of the Lysholm score, IKDC evaluation system, one-leg-hop test, KT-1000 laxity measurements, anterior knee pain and the patients' subjective evaluation of the results. However, the competitive athletes displayed a significantly higher reduction in Tegner activity level than the recreational athletes. The functional and objective results after anterior cruciate ligament reconstruction were comparable for the recreational and competitive athletes. We, therefore, conclude that anterior cruciate ligament reconstruction could be recommended for recreational athletes as well as competitive athletes.

A prospective four- to seven-year follow-up after arthroscopic anterior cruciate ligament reconstruction.

The aim of this study was to evaluate the results after arthroscopic anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft in 99 patients, who were followed up prospectively for four to seven years. The pre-injury Tegner activity level was 7 compared with 5 at the four- to seven-year follow-up (P<0.0001). The preoperative Lysholm score was 74.5 points. At the two-year follow-up, the Lysholm score was 95 points, while it was 90 points at the four- to seven-year follow-up (P<0.0001 preoperative vs two years and preoperative vs four to seven years and P<0.0005 two years vs four to seven years). Using the IKDC evaluation system, 80% of the patients were classified as normal or nearly normal and 20% as abnormal or severely abnormal at the final follow-up. The KT-1000 laxity measurements revealed a side-to-side difference of 2.9 mm preoperatively, 0.6 at two years and 1.0 mm at four to seven years. Twenty-six patients underwent additional surgery during the follow-up period. The results after arthroscopic reconstruction of the anterior cruciate ligament appear to be satisfactory both at the short- and the medium-term follow-ups, but there appears to be some deterioration between the two-year and the four- to seven-year follow-up.