Continuous passive motion in the prevention of deep-vein thrombosis: a randomised comparison in trauma patients.

There is a high risk of venous thromboembolism when patients are immobilised following trauma. The combination of low-molecular-weight heparin (LMWH) with graduated compression stockings is frequently used in orthopaedic surgery to try and prevent this, but a relatively high incidence of thromboembolic events remains. Mechanical devices which perform continuous passive motion imitate contractions and increase the volume and velocity of venous flow. In this study 227 trauma patients were randomised to receive either treatment with the Arthroflow device and LMWH or only with the latter. The Arthroflow device passively extends and plantarflexes the feet. Patients were assessed initially by venous-occlusion plethysmography, compression ultrasonography and continuous wave Doppler, which were repeated weekly without knowledge of the category of randomisation. Those who showed evidence of deep-vein thrombosis underwent venography for confirmation. The incidence of deep-vein thrombosis was 25% in the LMWH group compared with 3.6% in those who had additional treatment with the Arthroflow device (p < 0.001). There were no substantial complications or problems of non-compliance with the Arthroflow device. Logistic regression analysis of the risk factors of deep-vein thrombosis showed high odds ratios for operation (4.1), immobilisation (4.3), older than 40 years of age (2.8) and obesity (2.2).

Quality of life 20 years after arthrodesis of the ankle. A study of adjacent joints.

biotalar fusion is considered to be the standard treatment for end-stage post-traumatic arthritis of the ankle. We report a retrospective, objective long-term study of the quality of life of 17 patients with 18 arthrodeses of the ankle, over a period of more than 20 years. We looked particularly for correlation between clinical and radiological signs of osteoarthritis in adjoining joints. At serial physical examinations, clinical grades were awarded according to the Olerud Molander Ankle (OMA) score. Any degree of degenerative change in the adjoining joints was recorded on standing radiographs. Patients filled out a SF-36 Health Survey form. Subjectively, 50% of patients were not handicapped in the performance of daily activities and 44% were in the same job as at the time of injury. At follow-up the mean OMA score was 59.4 points, the visual analogue scale was 1.99 and the radiological score was 2.7. The SF-36 for physical function, emotional disturbance and bodily pain revealed significant deficits. There was a significant correlation between the OMA and the radiological score (p = 0.05), and between the clinical and the SF-36 score (p = 0.01), but no significant correlation between the radiological score and the SF-36 score. Arthrodesis of the ankle leads to deficits in the functional outcome, to limitations in the activities of daily living and to radiological changes in the adjoining joints. The clinical outcome score correlates closely with the SF-36 score.

[Is there a correlation between clinical results or quality of life and radiological findings after implantation of a total knee prosthesis?]. / Besteht eine Korrelation zwischen klinischen Ergebnissen oder der Lebensqualität und dem radiologischen Befund nach Implantation einer totalen Knieendoprothese?

AIM OF THE STUDY: To establish whether there is a clinical correlation between clinical outcome or quality of life and radiographic findings. MATERIAL AND METHODS: 17 patients (mean age 68.2 years) with total knee arthroplasty were examined after an average follow-up of 24.6 months. The examination included the HSS score for clinical parameters, and the SF-36 questionnaire quality of life. Radiographs were evaluated in accordance with Ewald and Lotke, and a schema of our own. RESULTS: The HSS score returned a mean of 81 points, and the SF-36 questionnaire showed significantly poorer results in comparison with age-matched healthy subjects. The Lotke evaluation of the X-rays showed a mean value of 76.3. Correlations between the radiographic findings and the HSS score were not seen. Correlations between X-ray parameters (Ewald and Lotke) and the SF-36 were found only for pain and vitality. CONCLUSIONS: This is the first study to investigate the correlation between clinical parameters (including quality of life) and X-ray findings. Neither the clinical score nor the quality of life score was found to correlate with the radiographic findings. Nor was more than minimal correlation found between quality of life and HSS score. These results show that the presence of radiolucent lines or deviations from the perfect prosthesis position must not necessarily be considered to be of importance for clinical outcome and quality of life.

[Oxidation of ultra high molecular weight polyethylene as a result of sterilization]. / Oxydation du polyéthylène de très haut poids moléculaire lors de la stérilisation.

PURPOSE OF THE STUDY: To improve (UHMWPE) Ultra High Molecular Weight Polyethylene quality for use in arthroplastic components, sterilization related oxidative changes were investigated in raw and manufactured material. MATERIAL: To evaluate sterilization related effects, 15 x 15 mm samples of UHMWPE were taken from a defined area of raw manufactured UHMWPE plates. The raw manufactured plates were produced using the compression molding method. For sterilization, gamma irradiation with and without air, ETO-sterilization and autoclave sterilization were performed. METHODS: Infrared spectroscopy was used to detect oxidation damage of the implant in superficial and deep layers of the material. RESULTS: Gamma sterilization on air showed 40% more oxidation compared with air-free sterilization. The superficial oxidation on air was 0.33 and showed the lowest value without air on argon with 0.155. Using ethylenoxide sterilization, no great changes in superficial oxidation (0.229) were observed; the smallest change (0.07) was observed at a depth of 2.79 mm. Autoclave sterilization caused the greatest superficial oxidation with 0.622 but low oxidation at 0.094 mm depth. In all samples, further oxidation and ongoing crystallinity was seen with increasing storage time. CONCLUSION: Ethylenoxide sterilization should be recommended for UHMWPE since oxidative changes is lowest. Gamma sterilization can only be recommended without air and at low doses.

Do functional deficits result from radial head resection?

The treatment of comminuted fractures of the radial head with primary or secondary head resection is controversial. To assess the outcome of patients after radial head resection, a retrospective study with clinical and radiologic follow-up including isokinetic testing was performed. Between 1981 and 1992, 151 patients underwent radial head resection for comminuted fractures. Fifty-nine patients were operated on during the first 2 weeks after injury (primary treatment), 47 patients were operated on between 3 weeks and 6 months after injury (early secondary), and 45 patients were operated on more than 6 months after injury (late secondary). Follow-up examinations of 108 patients were conducted at an average of 6 years after operation. In 64% of the patients only the radial head was fractured. In 26% of the patients the fracture was combined with a dislocation of the elbow. Results on the clinical and isokinetic tests were better for patients treated with primary resection than for patients treated with secondary resection. Of the patients treated with primary resection, 45% were subject to no restrictions in daily life and 64% had no limits at work.

Incidence and symptoms of clinically manifest rotator cuff lesions.

A clinical study of 200 unselected elderly subjects with an average age of 78 years living in retirement homes was performed to determine the prevalence of clinically manifest rotator cuff tears and the relevance of the tear for daily life. A comprehensive questionnaire was performed and the examination included the UCLA- and Constant-shoulder assessment scales and a multitude of special tests. The criteria for clinical diagnosis of a rotator cuff tear were a positive Jobe-test, diminished external rotation, a positive zero-degree-abduction test, the drop arm sign, pseudoparalysis and atrophy. By these criteria we found 28 (7%) rotator cuff tears in 25 people. There were 15 women and 10 men and the mean age of symptom onset was 55 years. Eleven craftsmen, 7 office workers and 7 housewives met our criteria for rotator cuff tears. Pain was present in 22 shoulders. Moderate weakness was found in 2 people and severe weakness in 22. In 20 people the range of motion was severely reduced and in 8 moderately reduced. Activities of daily living were impaired in all affected subjects. Eight people reported onset of symptoms after trauma. Patients with clinically diagnosed rotator cuff tears scored an average of 13 points in the UCLA-shoulder assessment scales and 40 points in the Constant-shoulder assessment scales. In conclusion rotator cuff may be symptomatic only in some people. Probably more anatomic than symptomatic rotator cuff tears exist, and it can be supposed that physical activities may be one possible reason for clinically relevant tears.

[New methods for effective prevention of thromboembolism in surgical medicine exemplified by trauma surgery]. / Neue Wege einer effektiveren Thromboembolieprophylaxe in der operativen Medizin am Beispiel der Unfallchirurgie.

Under conventional prevention (pharmacological and physical) of thromboembolism 30-40% of surgical patients develop deep vein thrombosis (DVT). Mechanical methods significantly increase the efficacy of prophylaxis for thromboembolism: these include intermittent pneumatic compression, A-V impulse systems and ankle motion devices. For all trauma patients it is advisable that conventional prophylaxis of thromboembolism be supplemented with elements of mechanical prophylaxis in order to reduce the continuing high thrombosis rate significantly.

[Ultrasound diagnosis of acute rupture of the anterior cruciate ligament. An experimental and clinical study]. / Sonographische Diagnostik der frischen Rupturen des vorderen Kreuzbands. Eine experimentelle und klinische Studie.

In an experimental study on 20 cadaver knee joints we found examined the ventral translation of the tibial head, which is otherwise shown by the Lachmann test, by dorsal sonography. These examinations were performed in knees in which arthroscopical examination had confirmed intact ACL. After endoscopical partial and complete rupture of the ACL the examinations were repeated. Radiological examination was performed as a reference method. In a sonographically standardized clinical study of 243 traumatized knee joints the ventral translation of the tibial head was evaluated. In all knee joints examined an arthroscopy or arthrotomy was performed. In 56% a rupture of the ACL was verified. There was a positive correlation between translation of the tibial head by 3 mm or more compared with the non-injured side and a rupture of the ACL (sensitivity 0.95; specificity 0.98). The dynamic sonographic technique is a simple and highly sensitive specific diagnostic method that can be used to quantify the results found on clinical examination.

[Ultrasound criteria of fresh rupture of the anterior cruciate ligament]. / Sonographische Kriterien der frischen Ruptur des vorderen Kreuzbandes.

In a prospective, controlled, monocentric clinical study 193 recently traumatized knee joints, suspicious of a ruptured anterior cruciate ligament, were examined sonographically. Three indirect signs of rupture were analyzed and compared to the results of the clinical tests of stability (Lachmann). Arthroscopy and arthrotomy were regarded as approved methods of reference. The sonographic pattern of an echo-free mass in the area of the femoral insertion of the anterior cruciate ligament proved to be more informative (sensitivity 0.91, specificity 0.78, effectivity 0.84) than the clinical signs of instability. A standardized sonographic examination of the knee joint should be a constant component of the posttraumatic examination. It is an inexpensive method, easy to learn and to perform, and is more reliable in the diagnosis of the ruptured anterior cruciate ligament than the clinical evaluation of instability.

[Physical prevention of thrombosis with the ankle joint with the motorized ankle joint movement device. Initial results of a clinical study]. / Physikalische Thromboseprophylaxe mit motorisierten Sprunggelenkbewegungsschienen. Erste Ergebnisse einer klinischen Studie.

Between 1993 and 1994 the value of the "Artroflow" device in deep venous thrombosis was tested in 95 trauma surgical high risk patients. Parallel to the application of Heparin and physical methods, the "Artroflow" device was employed. The test and compare group showed an equal amount of risk parameters and comparable injuries. In all patients until full mobilization a weekly clinical examination, a compression sonography of the deep leg veins and a venous Doppler examination was performed. In the test group 1 deep venous thrombosis (2.3%) and no clinically manifest lung embolism occurred. In the control group, the deep venous thrombosis rate was 21.6%. This showed a highly significant drop of the deep venous thrombosis rate in trauma surgical patients (p < 0.0041 Fisher test) and allows us to suggest the use of the "Artroflow" device in high risk patients parallel to heparin prophylaxis.