Prevention of dislocation of the hip in children with cerebral palsy. The first ten years of a population-based prevention programme.

In 1994, a register for cerebral palsy and a health-care programme were started in southern Sweden with the aim of preventing dislocation of the hip in children with cerebral palsy. It involved all children with cerebral palsy born in 1992 or later. None of the 206 affected children born between 1992 and 1997 has developed a dislocation following the introduction of the prevention programme. Another 48 children moved into the area and none developed any further dislocation. Of the 251 children with cerebral palsy, aged between five and 11 years, living in the area on January 1, 2003, only two had a dislocated hip. One boy had moved into the area at age of nine with a dislocation and a girl whose parents chose not to participate in the programme developed bilateral dislocation. One boy, whose condition was considered to be too poor for preventative surgery, developed a painful dislocation of the hip at the age of five years and died three years later. Eight of 103 children in a control group, consisting of all children with cerebral palsy living in the area between 1994 and 2002, and born between 1990 and 1991, developed a dislocation of the hip before the age of six years. The decreased incidence of dislocation after the introduction of the prevention programme was significant (p < 0.001). Dislocation of the hip in cerebral palsy remains a serious problem, and prevention is important. Our screening programme and early intervention when lateral displacement of the femoral head was detected appear to be successful.

Screening of neonatal instability and of developmental dislocation of the hip. A survey of 132,601 living newborn infants between 1956 and 1999.

Between 1956 and 1999, 132,601 living children were born in Malmö, and screened for neonatal instability of the hip. All late diagnosed patients have been followed and re-examined clinically and radiologically. During the first years of screening, less than five per 1,000 living newborn infants were treated. This figure increased to 35 per 1000 in 1980, but later diminished again to about six per 1,000 annually after 1990. The number of referred cases decreased from 45 per 1,000 in 1980 to between 10 to 15 per 1,000 from 1990. During the period of high rates of referral and treatment a larger number of paediatricians were involved in the screening procedure than during the periods with low rates of ferral and treatment. Altogether 21 patients (0.16 per 1,000) with developmental dislocation of the hip were diagnosed late, after one week. At follow-up, 18 were free from symptoms and 15 considered to be diologically normal.

Decreasing incidence of fractures in children: an epidemiological analysis of 1,673 fractures in Malmö, Sweden, 1993-1994.

The incidence of fractures in children in the city of Malmö, Sweden, almost doubled between 1950 and 1979. To see whether a further increase had occurred, we carried out an epidemiological analysis of fractures among children 0-16 years in Malmö 1993-1994. During the study period, 1,673 fractures occurred in 1,610 children. The commonest fracture location was the distal forearm (26%), followed by the phalanges of the hand (16%) and the clavicle (9%). The annual fracture incidence was 235/10(4) in boys, 149/10(4) in girls and 193/10(4) for both genders. This means a decrease in the annual fracture incidence by 9% since 1975-1979. The decrease was not associated with any specific type of fracture or etiological factor. Fractures of the distal forearm among girls were an exception to the general decline, having increased by one third since 1975-1979, which might be explained by the fact that today girls participate to a greater extent in the same sports as boys.

Alcohol abuse and healing complications after cervical hip fractures.

Osteonecrosis of the femoral head following femoral neck fractures is a common condition. Spontaneous osteonecrosis, is, however, a rare disorder, which is observed with increased frequency in alcohol abusers. In this retrospective study, we followed 512 consecutive male patients who had sustained femoral neck fractures between 1984 and 1992; 82 of these 512 patients (16%) had earlier been registered at the Department of Alcohol Diseases as high consumers of alcohol. The aim of the study was to determine the relationship between the rate of healing complications and alcohol consumption. No differences were observed in the degree of fracture dislocation, frequency of femoral head necrosis, and pseudoarthrosis among the abusers. Furthermore, no differences were found in causative events, primary operative treatment, post-operative complications, and the number of secondary operations. The abusers were significantly younger, had a higher rate of early retirement, and had an increased death rate. Our study suggests that alcohol complicates the healing process to a lesser extent than earlier thought, and that osteonecrosis of the femoral head after femoral neck fractures is equally common in non-abusers as in abusers.

Bone mineral density in adolescents. Higher values in a rural area--a population-based study of 246 subjects in southern Sweden.

We performed, in a cross-sectional study, dual energy X-ray absorptiometry (DXA) among 15-16-year-old boys (n 58) and girls (n 44) living in an urban area and among boys (n 82) and girls (n 66) of the same age from a rural area. We measured bone mineral density (BMD) of the total body, the lumbar spine and the hip. In the rural population, we found significantly higher BMD levels in the lumbar spine (14% for the boys and 12% for the girls) and the total body (6.9% for the boys and 3.4% for the girls). We detected no significant differences in the hip BMD. Adolescents in rural areas seem to develop a higher peak bone mass and thereby presumably have a lower risk of developing fragility fractures.

The relationship between childhood growth, bone mass, and muscle strength in male and female adolescents.

In this population-based study, the relationship between childhood weight and height, and adolescent bone mass and muscle strength have been studied in 39 girls and 48 boys. Total body and femoral neck bone mass measurements (bone mineral content, BMC and bone mineral density, BMD) were made by dual X-ray absorptiometry. Quadriceps muscle strength was measured. Mean age at the time of measurement was 15.1 years for girls and boys. Results were individually linked to data on childhood (birth to 6 years of age) weight and height, taken from community health records. Childhood weight was found to be predictive of adolescent total body BMC (TBMC). However, this was not the case when correlating childhood weight and total body BMD (TBMD), suggesting that growth determines the size of the skeleton, whereas the density within that bone envelope is to a greater extent governed by other factors. Further, in a multiple regression model we found that the combined effect of childhood weight and height was significantly correlated with adolescent quadriceps muscle strength.

Bone mineral density, muscle strength and physical activity. A population-based study of 332 subjects aged 15-42 years.

The aim of this population-based study was to find out whether differences in levels of physical activity have an influence on bone mass quantity and whether quadriceps muscle strength is a reliable determinant of bone mass. Included were 175 men and 157 women, aged 15-42 years. Bone mineral density (BMD) was measured at various sites by dual X-ray absorptiometry (DXA) and single photon absorptiometry (SPA). Muscle strength was assessed using an isokinetic muscle force meter. A questionnaire was used to estimate the level of physical activity. We found a positive correlation between physical activity and BMD for boys at the distal forearm and for girls at the trochanter (age group 15-16 years). Active men (age group 21-42 years) had up to 9% higher BMD levels at the hip than those who were less active. Quadriceps muscle torque was not an independent predictor of BMD. Our data suggest that a higher level of physical activity-within the limits of a "normal life style"-may have a positive effect on BMD in the proximal femur of young adults, which in turn may lessen the subsequent risk of fracture.

A single bone density measurement can predict fractures over 25 years.

The purpose of the present study was to determine the predictive ability of a single bone mineral density (BMD) measurement on a 25-year perspective. A group of 1076 women (age 20-78 years) had had their forearm BMD measured from 1970 to 1975. In those women that were still alive at the end of 1994 (n = 410), all fragility fractures (distal end of the radius, proximal end of the humerus, hip, and vertebra) that had occurred after the BMD measurement and that were roentgen verified were recorded, after a follow-up time of 20-25 years. Altogether, 213 fractures occurred in the cohort. In the age group > or = 40-70 (at time of BMD measurement) the relative risk (RR) associated with a 1 SD decrease of forearm BMD was 1.66 (CI 1.13-2.46) for a hip fracture (n = 43), 1.79 (CI 1.22-2.62) for a vertebral fracture (n = 63), and 1.33 (CI 1.20-1.73) for all fractures. In the age group 30-50, a fracture of the distal end of the radius after 20 years could be predicted; RR 1.90 (CI 1.02-3.55). These are slightly lower predictive values compared with previous studies of the same population with follow-up times of 11 and 13 years, especially with regard to hip fractures. However, the present study demonstrates that a single BMD measurement at the forearm has a predictive ability for fragility fractures--including hip fractures--on a 25-year perspective.

Importance of participation rate in sampling of data in population based studies, with special reference to bone mass in Sweden.

OBJECTIVE: To study the effects of participation rate in sampling on "normative" bone mass data. DESIGN: This was a comparison between two randomly selected samples from the same population. The participation rates in the two samples were 61.9% and 83.6%. Measurements were made of bone mass at different skeletal sites and of muscle strength, as well as an assessment of physical activity. SETTING: Malmö, Sweden. SUBJECTS: There were 230 subjects (117 men, 113 women), aged 21 to 42 years. RESULTS: Many subjects participated in both studies (163). Those who took part only in the study with the higher participation rate (67) almost invariably had higher values for bone mass density at the sites measured (up to 7.6% for men) than participants in the study with the lower participation rate. No differences in muscle strength were recorded. CONCLUSION: A high degree of compliance is important to achieve a reliable result in determining normal values in population based studies.

Bone mineral density in female junior, senior and former football players.

The purpose of this study was to examine the bone mineral densities (BMD) of female junior and senior football (soccer) players with different training regimens and histories, female former football players, and their respective controls. Active junior (age 13-17 years, n = 62) and senior (age 18-28 years, n = 34) players, representing three teams with different levels of performance and training, were compared reciprocally and with matched controls (n = 90). Former players (age 34-84 years, n = 25) who had ended their careers on average 9.7 years previously and their matched controls (n = 57) were also studied. Body composition and total body, lumbar spine and proximal femur BMD were measured with dual-energy X-ray absorptiometry. Former players and their controls were asked in a questionnaire to specify their current level of physical activity. In a control for differences in age, weight and body mass index, football players had significantly greater BMD than controls at all sites measured. This difference appeared to be site-specific, with greater differences in BMD at the proximal femur sites (10.5-11.1%) than at the lumbar spine (4.8%) or for the total body (3.5%). Further, differences were greater for senior than for junior players. However, no BMD differences were found between teams representing different levels of performance and training. Female former football players had retained their proximal femur and total-body BMD advantage over controls. In conclusion, training in female football, which is an impact-loading activity, has a site-specific, positive effect on bone formation that is not increased over a certain level of physical activity. The BMD advantage attained appears to be preserved to some extent after the termination of the athlete's active career, which may have a positive effect on future fracture risk.

Hip fractures in Nordic cities: difference in incidence.

All new hip fractures referred to hospital in 1989 were recorded in seven urban populations from Denmark, Finland, Norway and Sweden. The total population at risk (50 years and older) was 588,427, and 4075 fractures were observed (76.5% women). In all cities an age-dependent increase in incidence was found, and the female incidence was highest. When comparing the incidence rates after direct standardization, significant differences in hip fracture incidence were found between the cities for both women and men. The standardized relative rates seemed to decrease when moving south and east with the lowest rates found in Tampere, Finland. This indicates that factors which differ even between urban populations within a restricted geographical region may have an important impact on hip fracture incidence.

Complications after transpedicular stabilization of the spine. A survivorship analysis of 163 cases.

OBJECTIVES: The authors studied complications of transpedicular stabilization methods. SUMMARY OF BACKGROUND DATA: One hundred and sixty-three consecutive transpedicular stabilization procedures were performed between January 1987 and December 1991. The indications for stabilization were trauma (33 cases), metastatic spinal disorder (30 cases), spinal stenosis (33 cases), spondylolisthesis (27 cases), ankylosing spondylitis (6 cases), low back pain (22 cases), and miscellaneous (12 cases). METHODS: Patients records and the entire series of radiographs for each case were scrutinized by independent observers. All per- and postoperative complications, including implant loosening and fatigue, were recorded. Clinical and radiographic survivorship analyses of the implants were performed. RESULTS: Early complications were unusual and none were associated with permanent morbidity. The probability of not having the implant removed in the first postoperative year was 85%. There was a 40% risk of radiographic failure, defined as loosening or implant fatigue, at 6 months. The outcome was more favorable in cases in which anterior vertebral interbody fusion was also performed. CONCLUSIONS: Transpedicular fixation is a safe procedure with a low incidence of serious per- and early postoperative complications. The mechanical durability of transpedicular fixators used alone is a cause for concern.

Long-term results of fracture of the scaphoid. A follow-up study of more than thirty years.

Fifty-six patients who had had a fracture of the scaphoid from January 1950 through December 1959 were interviewed, re-examined, and had radiographs made of both hands an average of thirty-six years (range, thirty-one to forty years) later. The average age at the time of the treatment was twenty-eight years (range, fifteen to forty-five years). Fifty-two of the fifty-six patients were treated at the time of the fracture; the other four had a non-union when first seen. The rate of non-union for the fresh fractures at the most recent follow-up examination was 10 per cent (five of fifty-two). Dorsal intercalated-segment instability was found in three of the fifty-six patients; all three had a pseudarthrosis and manifest radiocarpal osteoarthrosis. Marked radiocarpal osteoarthrosis developed in only one (2 per cent) of the forty-seven patients who had a healed fracture; it was far more common in the group that had a pseudarthrosis, in which the prevalence was five of nine patients. Manifest osteoarthrosis also seemed to be associated with pain or weakness: it had developed in only three (6 per cent) of the forty-nine patients who did not have any symptoms at the re-examination, compared with three of the seven who had symptoms.

Incidence of hip fractures in Malmö, Sweden (1950-1991).

In a 24-year sub-sample taken from a 42-year period of study (1950-1991), hip fracture incidence was analysed from a defined catchment area within one hospital. During this time, 8,256 hip fractures occurred in a generated risk population of 1,915,571 person-years. Crude incidence increased three-fold in women and five-fold in men. In men, the age-specific increase was twice as large as the age drift. In women, the two components were of equal size. The more marked increase in men caused the female:male ratio to decrease from 4.2 in 1950 to 2.4 in 1991. In men, all age classes experienced a significant yearly increase (1.6% in the 50-59 age group, 3.9% over the age of 80). In women, only the 70-79 and 80+ age groups showed a significant increase (1.4%, 2.3%). In the age-standardised curve, a levelling off occurred during the mid-80s. In women, this was attributable to changes in climate during wintertime. In men, no significant association was found with temperature. The age-standardised curve followed an approximate linear trend with an increase of 6.4/100,000/year in women and 4.9/100,000/year in men. The cumulative rate for the age group 50-79 years doubled in men but increased only by one-third in women. The impact of increasing incidence in men compared with women is discussed using an osteoporosis model consisting of base risk, senile risk, and post-menopausal risk.

Bone mineral content in women: trends of change.

Altogether 426 women had their forearm bone mineral content (BMC) measured with single photon absorptiometry (SPA): one group in the early 1970s, another about 18 years later. Both groups represented purportedly healthy subjects. A third group of 328 women, measured at the same time as the second group, was from the same population but chosen by random selection (the population-based group). In the two sets of non-population-based women there was a small percentage reduction in the cortical forearm bone mass in the recent measurement as compared with the earlier measurement. This was significant only in women below 70 years of age. The forearm BMC, both cortical and trabecular, was less in all age groups of women randomly selected from the same population as the healthy control sample. This difference emphasizes the importance of selecting normative data from a population-based sample.

Piroxicam and indomethacin suppositories for painful coxarthrosis.

Six orthopaedic clinics in Sweden made a comparison of the effects and side effects of Piroxicam (20 mg) and Indomethacin (100 mg) suppositories in 261 patients with painful coxarthrosis on the waiting list for total hip replacement (THR). The study was designed as a single blind study over 4 weeks. Amount of pain and range of motion was registered before the trial and compared with findings after 4 weeks, including reported side effects. Both drugs gave satisfactory pain relief without any appreciable variation on weightbearing or at rest. On the other hand, the trial showed a significant difference (p = 0.0033, Student's-test) between the two drugs as regards the frequency of side effects from the lower gastrointestinal tract, where piroxicam had a lower rate compared with indomethacin. No serious complications occurred; 16 patients dropped out, 8 in each group.

Silicone rubber implants for arthrosis of the scaphotrapezial joint.

Between 1980 and 1983, 10 patients received high performance silicone rubber condylar implants for the treatment of isolated degenerative changes of the scaphotrapezial joint. Early clinical and radiographic results (at a mean of 15 months) were excellent. Late follow up of these 10 together with a further 11 patients, however, showed migration of the implant and radiological signs of silicone particle synovitis in all but two. We no longer recommend this operation for treatment of isolated arthrosis of the scaphotrapezial joint.