Results of Operative and Nonoperative Treatment of Rockwood Types III and V Acromioclavicular Joint Dislocation: A Prospective, Randomized Trial With an 18- to 20-Year Follow-up.

BACKGROUND: The optimal treatment of acute, complete dislocation of the acromioclavicular joint (ACJ) is still unresolved. PURPOSE: To determine the difference between operative and nonoperative treatment in acute Rockwood types III and V ACJ dislocation. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: In the operative treatment group, the ACJ was reduced and fixed with 2 transarticular Kirschner wires and ACJ ligament suturing. The Kirschner wires were extracted after 6 weeks. Nonoperatively treated patients received a reduction splint for 4 weeks. At the 18- to 20-year follow-up, the Constant, University of California at Los Angeles Shoulder Rating Scale (UCLA), Larsen, and Simple Shoulder Test (SST) scores were obtained, and clinical and radiographic examinations of both shoulders were performed. RESULTS: Twenty-five of 35 potential patients were examined at the 18- to 20-year follow-up. There were 11 patients with Rockwood type III and 14 with type V dislocations. Delayed surgical treatment for ACJ was used in 2 patients during follow-up: 1 in the operatively treated group and 1 in the nonoperatively treated group. Clinically, ACJs were statistically significantly less prominent or unstable in the operative group than in the nonoperative group (normal/prominent/unstable: 9/4/3 and 0/6/3, respectively; P = .02) and in the operative type III (P = .03) but not type V dislocation groups. In operatively and nonoperatively treated patients, the mean Constant scores were 83 and 85, UCLA scores 25 and 27, Larsen scores 11 and 11, and SST scores 11 and 12 at follow-up, respectively. There were no statistically significant differences in type III and type V dislocations. In the radiographic analysis, the ACJ was wider in the nonoperative than the operative group (8.3 vs 3.4 mm; P = .004), and in the type V dislocations (nonoperative vs operative: 8.5 vs 2.4 mm; P = .007). There was no statistically significant difference between study groups in the elevation of the lateral end of the clavicle. Both groups showed equal levels of radiologic signs of ACJ osteoarthritis and calcification of the coracoclavicular ligaments. CONCLUSION: Nonoperative treatment was shown to produce more prominent or unstable and radiographically wider ACJs than was operative treatment, but clinical results were equally good in the study groups at 18- to 20-year follow-up. Both treatment methods showed statistically significant radiographic elevations of the lateral clavicle when compared with a noninjured ACJ.

Magnetic resonance imaging of acute scrotum.

BACKGROUND AND AIMS: The aim of the pilot study was to evaluate the feasibility of dynamic contrast enhanced (CE)-magnetic resonance imaging (MRI) in the detection of testicular ischemia and its ability to differentiate testicle torsion from other causes of acute scrotum. MATERIAL AND METHODS: Seventeen boys or young men with an acute scrotum were included in the prospective study during the time period from October 2001 to December 2005. The median age of the patients was 16,4 (7-44) years. The duration of the symptoms preceding the MRI study varied from six hours to 30 days. The study protocol included physical examination by a surgeon, laboratory tests and Doppler ultrasound (DUS) and finally testicles were imaged by using a 1,5 T MRI scanner; T1-weighted and diffusion weighted images were produced. The gadolinium uptake, reported as the region of interest (ROI) perfusion values and presented as curves, was compared between the affected and contralateral testicle. In testicles with normal blood circulation the ROI values increased during the imaging time. Nine patients were operated on, because the spermatic cord torsion could not be excluded by clinical or DUS findings. RESULTS AND CONCLUSIONS: All the normal testicles gave increasing ROI values meanwhile all three testicles with torsion gave constantly low values referring to no perfusion. Other causes of acute scrotum, such as epididymitis and torsion of testicular appendage seemed to be related with normal perfusion. Dynamic CE-MRI seems to show reliably ischemia of testicle and thus it may be helpful in selecting patients with acute scrotum for urgent operation.

Non-absorbable interrupted versus absorbable continuous skin closure in pediatric appendectomies.

BACKGROUND AND AIMS: appendectomy wounds are still commonly closed with non-absorbable sutures. Stitch removal has financial costs and causes anxiety in children. Our aim was to compare interrupted non-absorbable (NA) and continuous intradermal absorbable (A) sutures in appendectomy wounds to evaluate whether absorbable suturing increases the risk of complications. MATERIAL AND METHODS: 198 children (age 4-18 years) including perforated cases were prospectively randomized into two groups (NA and A skin closure). The wounds and inflammatory markers were evaluated on the first two postoperative days. The appearance of the wound was evaluated one week postoperatively by a district nurse. Follow-up data were obtained from 166 patients (87 in NA group and 79 in A group). RESULTS: in NA group 86 % and in A group 81 % had appendicitis (8 % and 15.6 % perforated and 9.3 % and 25 % gangrenous cases in NA and A groups, respectively). The total wound infection rate was low, 1.8 % (2.3 % in NA Group and 1.3% in A Group). No differences in the inflammatory markers or the appearance of the wound were noted between the groups, but nine children in NA Group (10.3 %) had a partial wound dehiscence after stitch removal. CONCLUSION: appendectomy wounds in children can be closed with continuous, absorbable sutures, even in complicated cases.

Fixation of experimental osteotomies with bioabsorbable SR-polylactide-polyglycolide (80/20) polymeric rods.

Self-reinforced polylactide-polyglycolide (80/20) composite rods, 2 mm in diameter and 36 mm in length, were implanted into the dorsal subcutaneous tissue of 20 rabbits. Osteotomies of the distal femur were fixed with these rods (2x15 mm) in the rabbits. The follow-up times varied from 3 to 104 weeks. After sacrifice, three-point bending and shear tests and molecular weight measurements were performed for subcutaneously placed rods. Radiological, histological, microradiographic, oxytetracycline-fluorescence, and histomorphometrical studies of the osteotomized and intact control femora were performed. After 6 weeks the mechanical properties had decreased significantly, but osteotomies had healed uneventfully. The present investigation showed that the mechanical strength and fixation properties of SR-Polylactide-glycolide (80/20) rods are suitable for fixation of cancellous bone osteotomies in rabbits provided that the operative technique is correct. The present article is the first report on the application of these rods for fixation of cancellous bone osteotomies.

A 19-year review of paediatric patients with acute scrotum.

BACKGROUND AND AIMS: The aim of the study was to compare incidence, symptoms and signs of spermatic cord torsion to those of other conditions causing acute scrotum. MATERIAL AND METHODS: Records of 388 consecutive boys under 17 years of age treated for acute scrotum at The Hospital for Children and Adolescents in Helsinki in 1977-1995 were reviewed. During the period studied all patients with acute scrotum underwent urgent surgery to ensure accurate diagnosis and treatment. The duration and characteristics of the symptoms, clinical findings prior to operation and the age of the patients were registered. RESULTS: Scrotal explorations revealed 100 cases (26%) of spermatic cord torsion (SCT), 174 cases (45%) of torsion of the testicular appendage (AT), 38 cases (10%) of epididymitis (ED), 32 cases (8%) of incarcerated inquinal hernias and 44 (11%) other conditions. During the first year of life SCT was the most common cause of acute scrotum, another peak incidence being in adolescence. Almost half of the boys with AT were nine to 12 years of age (median 11). Except for infants, the patients' acute symptoms were pain (SCT 88%, AT 94%, ED 76%). Swelling in the hemiscrotum was found in 44% of SCT, in 39% of AT and in 88% of ED cases. Epididymitis was also accompanied by erythema (37%), but infrequently with fever (in 16%). Erythema was found also in AT (32%), but the "blue dot sign" was found positive in only 17 (10%) of the boys with AT. Three quarters of the boys who were operated on within six hours from onset of symptoms had testicle torsion. All testicles were saved when detorsion was performed within six hours, but salvage was possible in only half of the cases when symptoms had lasted more than six but less than 12 hours. CONCLUSIONS: The high probability of SCT among those admitted to an emergency department within six hours from the onset of the symptoms justifies immediate surgical exploration.

Magnetic resonance imaging of experimental testicular torsion.

We investigated the feasibility of contrast enhanced (CE)-dynamic magnetic resonance imaging (MRI) for the detection of testicular torsion induced hypoperfusion in an experimental rat model. Adult Sprague-Dawley rats were subjected to unilateral testicular torsion of 360 or 720 degrees. After 1 h, the tail veins of the anaesthetized rats were cannulated and T2 -, diffusion-weighted and T1-weighted CE-dynamic MRI were subsequently performed by a 1.5 T MRI scanner. On apparent diffusion coefficient (ADC) images, the region of interest values of the ischaemic and control testes was compared. From CE-dynamic MR images, the maximal slopes of contrast enhancement were calculated and compared. In testicular torsion of 360 degrees, the maximal slope of contrast enhancement was 0.072%/s vs. 0.47%/s in the contralateral control testis (p < 0.001). A torsion of 720 degrees diminished the slope of contrast enhancement to 0.046%/s vs. 0.37%/s in the contralateral testis (p < 0.001). Diminished blood flow during torsion also followed in decreased ADC values in both 360 degrees (12.4% decrease; p < 0.05) and 720 degrees (10.8% decrease; p < 0.001) of torsion. Torsion of the testis causes ipsilateral hypoperfusion and decreased gadolinium uptake in a rat model that can be easily detected and quantified by CE-dynamic MRI. In diffusion-weighted MRI images, acute hypoperfusion results in a slight decrease of ADC values. Our results suggest that CE-dynamic MRI in combination with diffusion-weighted MRI can be used to detect compromised blood flow due to acute testicular torsion.

Gamma probe localization in the surgical treatment of osteoid osteoma.

BACKGROUND: Osteoid osteoma is a benign bone tumor typically inducing night pain. It has traditionally been treated with operative excision. An accurate localization and complete removal of the small lesion is difficult resulting in high recurrence rate and reoperations. AIMS: The purpose of the present study was to examine the applicability of a hand-held gamma probe in the intraoperative localization of an osteoid osteoma. MATERIAL AND METHODS: Five patients were examined and operated for osteoid osteoma. Dose of 740 MBq Technetium 99m was injected 3 hours before operation, and hand-held gamma probe was used for the intraoperative detection of the lesion. RESULTS: All patients were relieved their symptoms. A histologically confirmed, complete removal of the lesion was achieved in 4 of 5 patients. No recurrences has been seen in the follow-up of 6 years. CONCLUSIONS: The gamma probe is an useful tool in the surgical treatment of osteoid osteoma. The technique is rapid and simple resulting in more accurate excision of the small lesion.

Percutaneous bone grafting in the treatment of the delayed union and non-union of tibial fractures.

The classic method of open bone grafting in the treatment of un-united tibial fractures has been associated with some complications. A novel, minimally invasive, percutaneous technique of bone grafting is described. Forty-one consecutive patients with delayed union or non-union of a tibial fracture was treated with percutaneous bone grafting from 1993 to 1999. The mean age of the patients was 41 (15-86) years. Twenty-seven patients had grade I-III open fractures. The fractures had initially been treated in a cast (n=26), external fixator (n=14) or intramedullary nail (n=1). Two patients had an earlier unsuccessful Phemister-Charnley-type bone-grafting procedure for delayed union. The mean interval from injury to percutaneous bone grafting was 21 (13-66) weeks. Thirty-seven of the 41 un-united fractures healed in 13 (10-48) weeks after the percutaneous bone grafting. The mean hospital stay was 1 day. No infections, bleeding or neural complications existed. Percutaneous bone grafting appeared to be as effective as open techniques, and possessed considerable advantages. It is safe, time saving and economical, it involves minimal trauma at the fracture site and it avoids major donor site problems.

Strength retention of drawn self-reinforced polyglycolide rods and fixation properties of the distal femoral osteotomies with these rods. An experimental study on rats.

Drawn self-reinforced polyglycolide (SR-PGA) rods, Ø 2 mm and 26 mm long, were implanted in the dorsal subcutaneus tissue of 16 rats. Osteotomies of the distal femur were fixed with SR-PGA rods (2 mm by 15 mm) in another 38 rats. The follow-up times varied from one week to one year. After sacrifice, three-point bending and shear tests were performed for subcutaneously placed rods. Radiological, histological, histomorphometrical, microradiographic, and oxytetracycline-fluorescence studies of osteotomized and intact control femora were also performed. At three weeks the flexural strength of the rods was 50% of the initial value, and the flexural modulus was 46% of the initial value. Five osteotomy specimens had to be excluded due to dislocation or non-union. One of the 33 evaluated osteotomy specimens showed signs of postoperative infection. Thirty-two osteotomies healed uneventfully. No gross signs of inflammatory or foreign-body reaction were observed. The amount of osteoid surface and active osteoid formation surface reached their highest value in the histomorphometrical analysis at 24 weeks. The present investigation demonstrated that the mechanical strength and fixation properties of the drawn SR-PGA rods are suitable for fixation of cancellous bone osteotomies in rats. The present article is the first report on the successful application of drawn SR-PGA rods for fixation of cancellous bone osteotomies.

Bioabsorbable fixation in orthopaedic surgery and traumatology.

Bioabsorbable internal fixation devices were introduced clinically in the treatment of fractures and osteotomies of the extremities at the Department of Orthopaedics and Traumatology, Helsinki University, in 1984. Since November 5, 1984, a total of 3200 patients were managed using bone or ligament fixation devices made of self-reinforced (matrix and fibres of the same polymer) bioabsorbable alpha-hydroxy polyesters. The devices used included cylindrical rods, screws, tacks, plugs, arrows, and wires. The most common indication for the use of bioabsorbable implants was the displaced malleolar fracture of the ankle. Transphyseal fixation with small-diameter, mainly polyglycolide pins was used in children. The postoperative clinical course was uneventful in more than 90% of the patients. The complications included bacterial wound infection in 4% and failure of fixation in 4%. In one-fifth of the latter cases, however, re-operation was not necessary. The occurrence of non-infectious foreign-body reactions two to three months postoperatively has been observed in 2% of the patients operated in the last few years with polyglycolide implants but none of the patients managed with polylactide implants. This inflammatory tissue response often required aspiration with a needle but did not influence the functional or radiologic result of the treatment. Owing to the biodegradability of these internal fixation devices, implant removal procedures were avoided. This results in financial benefits and psychological advantages. Bioabsorbable implants can also be used in open fractures and infection operations.

Hypothyroidism and depression: a therapeutic challenge.

OBJECTIVE: To describe a patient with longstanding depression and hypothyroidism who had marked mood improvement only after triiodothyronine (T3) was added to her thyroxine (T4) replacement therapy. CASE SUMMARY: A 50-year-old white woman had a long history of depression and documented hypothyroidism since 1991. Despite treatment with T4 with dosages up to 0.3 mg/d, she continued to be depressed, have symptoms of hypothyroidism, and have a persistently elevated thyroid-stimulating hormone concentration. Addition of a low dose of T3 to her regimen resulted in significant mood improvement. DISCUSSION: The relationship between hypothyroidism and depression is well known. It is possible that this patient's long history of depression may have been a consequence of inadequately treated hypothyroidism, due either to poor patient compliance or resistance to T4. Nevertheless, her depression responded to addition of a low dose of T3 to her regimen. This case emphasizes the importance of screening depressed patients for hypothyroidism. Her clinical course also suggests that depression related to hypothyroidism may be more responsive to a regimen that includes T3 rather than to replacement with T4 alone. This is consistent with the observation that T3 is superior to T4 as adjuvant therapy in the treatment of unipolar depression. CONCLUSIONS: Depressed patients should be screened for hypothyroidism. In hypothyroid patients, depression may be more responsive to a replacement regimen that includes T3 rather than T4 alone. Therefore, inclusion of T3 in the treatment regimen may be warranted after adequate trial with T4 alone.

Strength retention of self-reinforced drawn poly-L/DL-lactide 70/30 (SR-PLA70) rods and fixation properties of distal femoral osteotomies with these rods. An experimental study on rats.

Self-reinforced polylevo-dextro-lactic acid (SR-PLA) 70 composite rods, (2 mm x 26 mm) were implanted in the dorsal subcutaneus tissue of sixteen rats. Osteotomies of the distal femur were fixed with SR-PLA70 composite rods (2 mm x 15 mm) in 39 rats. The follow-up times varied from 1 week to 1 year. After sacrifice three-point bending and shear tests were performed for subcutaneously placed rods, and radiological, histological, histomorphometrical, microradiographic, and oxytetracycline-fluorescence studies of osteotomized and intact control femora were performed. At 52 weeks the shear strength and flexural modulus of the rods were 41% of the initial value, and the flexural strength was 43% of the initial value. In the osteotomies seven specimens had to be excluded due to postoperative infection or dislocation of the fragment. Six of the thirty-two evaluated osteotomies showed signs of postoperative infection. Twenty-six osteotomies healed uneventfully. No signs of inflammatory or foreign-body reaction were observed. The present investigation demonstrated that the mechanical strength and fixation properties of the SR-PLA70 rods are suitable for fixation of cancellous bone osteotomies in rats. The present article is the first report on successful application of SR-PLA70 rods for fixation of cancellous bone osteotomies studied.

Application of a self-reinforced polyglycolic acid (SR-PGA) membrane to the closure of an abdominal fascial defect in rats.

The suitability of a polyglycolic acid (PGA) membrane to fascial closure was tested in 40 rats. To induce collagen synthesis, a fascial strip from the vastus lateralis muscle was applied to the peritoneal side of the PGA membrane. A midline laparotomy was performed, and the incision was covered with the membrane fixed at the edges. The animals were sacrificed at 3, 6, 12, and 28 weeks, at which time macroscopical, histological, and electron microscopical findings, as well as the results of breaking force tests were evaluated. Fascial augmentation had no effect on the results. Ventral hernias were observed in 37.5% of the cases, half of which were observed after 6 weeks postoperatively. In one case, intestinal adhesions to the membrane were found. Inflammatory reaction during the follow-up was moderate and lasted up to 12 weeks. Breaking force decreased up to 6 weeks, after which it slightly increased without reaching the breaking force level of the control animals.

Predicting the development of a homogeneous population in an industrialized country.

The development of the Finnish population has been studied in order to predict its probable changes in the 21st century. More generally, the proposed iterative prediction procedure is useful for homogeneous populations in developed countries. The Finnish population is favorable for demographic studies because there exists accurate Finnish population data for a long historical period. Since several factors, for example natality, mortality, average female fertility and standard of living, have an impact on population, its modeling and prediction is an intricate matter. First, neural networks that are often efficient for nonlinear, complex systems were tried. However, it was found that there were far too many input parameters and a critical shortage of data to train and test neural networks. Instead, a straightforward, iterative procedure to predict the future development of the Finnish population was created, in particular giving its probable upper and lower limits.

Mechanical properties and strength retention of carbon fibre-reinforced liquid crystalline polymer (LCP/CF) composite: an experimental study on rabbits.

A novel composite material with ultra-high flexural strength and cortical-bone-matched elastic modulus made of liquid crystalline polymer reinforced with carbon fibres (LCP/CF) is described. Cylindrical rods of 3.2 mm diameter and 50 mm length were fabricated by a preimpregnation/pultrusion method. The initial mechanical properties of the LCP/CF rods were as follows: flexural strength 448 MPa, flexural modulus 43 GPa, shear strength 164 MPa, and interlaminar shear strength 15.3 MPa. In the in vitro study the LCP/CF rods were immersed in phosphate-buffered saline of 37 degrees C for 12, 24, and 52 weeks. In the in vivo study the LCP/CF rods were implanted into the medullary cavity of both femora and subcutaneous tissue of the New Zealand White rabbits for 12, 24, and 52 weeks. The flexural strength of the LCP/CF rods at 52 weeks was 463 MPa in saline, 467 MPa in the subcutaneous tissue and 466 MPa in the medullary cavity of the femur. The flexural modulus was 44.6, 48.9 and 46.2 GPa, respectively. The corresponding shear strength values were 160, 178 and 181 MPa. We conclude that the LCP/CF is a promising material for high-load applications and the LCP/CF rods retain their initial mechanical properties in one-year follow-up in vivo and in vitro.

Saccharomyces boulardii for the treatment of Clostridium difficile-associated colitis.

S. boulardii has been investigated in Europe and the US, and preliminary reports indicate that it is safe and effective in conjunction with vancomycin or metronidazole for the treatment of CDC, predominantly in patients who develop recurrence. S. boulardii in combination with vancomycin or metronidazole has not been shown to be more effective than either of these agents alone for treatment of a first episode of CDC. In addition, S. boulardii has not been studied in immunocompromised patients who may be at risk for developing fungemia. Ultimately, large-scale clinical studies are necessary to determine whether S. boulardii should be routinely used to treat patients with recurrent CDC. S. boulardii is currently undergoing Phase III clinical trials for CDC treatment in the US. Clinicians interested in information regarding participation in current studies may contact Biocodex Inc., in Seattle, Washington.

Bioresorbable implants: applications in orthopaedic surgery.

There are several new and potential uses for absorbable implants. Some will provide exciting options in the future. Ongoing animal and clinical studies will help focus future areas of development.

On the nature of Wisconsin Card Sorting Test performance in schizophrenia.

Performance on the Wisconsin Card Sorting Test (WCST) is widely reported to be impaired in patients with schizophrenia. It has been hypothesized that the performance deficit on the WCST in schizophrenia is related to a dysfunction of the frontal lobe, specifically the dorsolateral prefrontal cortex. This hypothesis was tested by comparing a group of patients with schizophrenia to patients with low grade right or left frontal lobe tumors and a group of patients with non-frontal high grade tumors. The results demonstrated a remarkable similarity in performance on the WCST between patients with schizophrenia and patients with right frontal lobe tumors. Patients with left frontal lobe tumors, non-frontal tumors, and normal control subjects did not show the same pattern of performance. This study provides support for frontal lobe dysfunction in the symptomatology of schizophrenia.