The importance of a multidisciplinary group in the treatment of soft tissue sarcomas.

In 1987, a multidisciplinary soft tissue sarcoma (STS) group was established and a treatment protocol was set up. By 1993, there were 193 patients with a diagnosis of STS of the superficial trunk or extremities. 134 patients were referred with primary (stage M0) tumours and treated with curative or palliative intention. Nine amputations were performed. 94 (70%) patients were treated with wide or compartment surgery (n = 62) or marginal surgery combined with postoperative radiotherapy (n = 32). According to the protocol, these patients had received adequate treatment. 18 patients have recurred locally (13%) (median follow-up: 36 months). 12 were salvaged. 33 had metastases. The estimated 3-year survival, local control and disease-free survival rates are 79, 87 and 69%, respectively. These results compare favourably with previously published results from this hospital and from a nationwide study. The improved results emphasise the importance of a multidisciplinary STS group.

Auditory disturbance associated with interscalene brachial plexus block.

We performed an audiometric study in 20 patients who underwent surgery of the shoulder region under an interscalene brachial plexus block (IBPB). Bupivacaine 0.75% with adrenaline was given followed by a 24-hr continuous infusion of 0.25% bupivacaine. Three audiometric threshold measurements (0.25-18 kHz) were made: the first before IBPB, the second 2-6 h after surgery and the third on the first day after operation. In four patients hearing impairment on the side of the block was demonstrated after operation, in three measurements on the day of surgery and in one on the following day. The frequencies at which the impairment occurred varied between patients; in one only low frequencies (0.25-0.5 kHz) were involved. The maximum change in threshold was 35 dB at 6 kHz measured at the end of the continuous infusion of bupivacaine. This patient had hearing threshold changes (15-20 dB) at 6-10 kHz on the opposite side also. IBPB may cause transient auditory dysfunction in the ipsilateral ear, possibly via an effect on sympathetic innervation.

Intraarticular morphine for pain relief after knee arthroscopy performed under regional anaesthesia.

Eighty patients scheduled to undergo knee arthroscopy were studied in random and double blind fashion. Spinal anaesthesia with hyperbaric 0.5% bupivacaine was selected for 40 overnight-in-patients. At the end of arthroscopy, 1 mg morphine or saline was injected intraarticularly. Local anaesthesia with 1% lidocaine plus adrenaline, was selected for another 40 out-patients. At the end of the arthroscopy either 1 mg morphine or saline was injected intraarticularly. As a rescue medication the spinal anaesthesia patients received oxycodone 0.14 mg kg-1 i.m. or ketoprofen 100 mg p.o. and the local anaesthesia patients received ketoprofen 100 mg p.o. The need for additional postoperative analgesic was almost similar in both spinal anaesthesia groups. The patients having local anaesthesia and given intraarticular morphine needed fewer doses of ketoprofen (22 doses) postoperatively than the control group (39 doses) (P < 0.05). Duration of analgesia was slightly longer after morphine than in the control group (ns). There was no difference between the morphine patients and the control patients in the two studies regarding the incidence of side effects. We conclude that postoperative analgesia in patients undergoing knee arthroscopy under local anaesthesia, but not under bupivacaine spinal anaesthesia, can be improved with a single intraarticular injection of 1 mg morphine.

Injuries in competitive junior ice-hockey. 1437 players followed for one season.

During one season we followed 1437 ice-hockey players, 9-18 years of age, participating in a junior league. We found 128 injuries (9 percent) that caused the player to miss at least one training session or game. One third of the injuries were a result of foul play. The most common types of injury were contusions, sprains, and lacerations. However, fissures and fractures were surprisingly frequent, reflecting foul play with the stick and improper use of the protective equipment. Thanks to the mandatory use of a completely-covering face protector, there were few maxillofacial injuries. The highest yearly incidence of injuries was found in the older players. Prevention of ice hockey injuries is multifactorial, including stricter rule enforcement, improved protective equipment, and better understanding of the forces involved.

Effect of continuous interscalene brachial plexus block on diaphragm motion and on ventilatory function.

Interscalene block may cause phrenic nerve block and decreased diaphragmatic motion. We evaluated the effect of continuous interscalene block on ventilatory function and diaphragmatic motion. We studied ten patients scheduled for surgery or manipulation of the shoulder. Preoperatively, the patients underwent spirometry and double-exposure chest radiography. They received an interscalene block with 0.75% bupivacaine. Thereafter, 0.25% bupivacaine was infused into the interscalene space for 24 h. Spirometry was repeated three times and double-exposure radiography twice. The maximal inspiratory and expiratory pressures were measured repeatedly. Haemoglobin oxygen saturation (SPO2) was monitored with pulse oximetry. The block provided adequate anaesthesia for surgery or manipulation. All patients had a marked ipsilateral paresis of the diaphragm in the radiographs 3 h after the initial block. Twenty-one hours later five patients had diaphragmatic motility comparable to the situation before the block. In the other five patients, the amplitude of diaphragmatic motility on the side of the block was only 4-37% of the values before the block. All patients had a clear reduction in forced vital capacity (FVC), forced expiratory volume in 1s (FEV1) and peak expiratory flow (PEF) 3 and 8 h after the block without signs of dyspnoea. In conclusion, in all our patients interscalene block caused an ipsilateral hemidiaphragm paresis, which in five of ten patients persisted until the end of the continuous block.

Resistance of a defect of the supraspinatus tendon to intraarticular hydrodynamic pressure: an experimental study on rabbits.

The healing of a standardized defect of the supraspinatus tendon in a time-related series on rabbits was monitored with arthrography and simultaneous determination of the intra-articular hydrodynamic pressure of the glenohumeral joint. All normal glenohumeral joints produced a biphasic pressure versus volume curve. Rupture of a normal glenohumeral joint occurred at a pressure level of 140-170 mm Hg and was located in the area around the biceps tendon sheath. In joints with a defect of the supraspinatus tendon, leakage of the contrast medium was evident up to the sixth week, at an intra-articular pressure varying from 40 to 100 mm Hg. After week 6, no leakage of the cuff was seen during the determination of the intraarticular pressure. This was in accordance with the histological findings: the defect was covered with solid scar tissue from the ninth week onward. Resistance to hydrodynamic intraarticular pressure proved a reliable method of determining the strength of the healing of the supraspinal defects.

Subacromial impingement decompressed with anterior acromioplasty.

Symptomatic (Stage II) impingement of the rotator cuff against the coracoacromial arch has been treated with anterior acromioplasty in 60 shoulders in 56 patients. Patient selection is crucial. Arthrography of the shoulder was routinely included in the preoperative diagnostic tools to rule out a tear of the rotator cuff. Since acromial shape may play a role producing a resistant impingement syndrome, special attention should be paid to patients with Type III of acromial inclination. The surgical procedure should include a thorough examination of the subacromial space as a whole, taking notice of all pathologic findings in the subacromial arch as well as in the underlying soft tissues. Restoring subacromial clearance, the patients were relieved of their symptoms. The result, rated according to the functional assessment of Neer, was excellent or satisfactory in 73%. Failure to recognize the associated bony as well as soft-tissue subacromial lesions was, however, a frequent cause of failure of surgical decompression operations.

Structure and function of the rabbit's supraspinatus muscle after resection of its tendon.

The tendinous part of the supraspinatus muscle was removed in 12 rabbits in order to simulate a major rotator cuff tear. Changes in the contractile response and the development of atrophy of the supraspinatus muscle were significant. These changes may indicate that the modest results obtained in reconstruction of major rotator cuff tears may be due to muscular insufficiency.

Fractures of the proximal humerus involving the intertubercular groove.

The purpose of this study was to analyse the involvement of the gliding surface of the biceps tendon in fractures of the proximal humerus. Fifteen patients had a fracture of the proximal humerus verified with antero-posterior and axillary radiographs. Tangential radiographs of the intertubercular groove, obtained from the shoulder joint, showed involvement of the intertubercular groove in 13 patients (87%), which could not be shown with other projections. Groove radiographs revealed in 3 patients a dislocation of the fragments of the greater tuberosity large enough to require surgical treatment, but which had not been found using conventional techniques. Therefore, a groove radiograph should be used to precise fractures of the proximal humerus.

Ultrasonography in lesions of the rotator cuff and biceps tendon.

Ultrasonography (US) of the shoulder joint was performed in 88 patients, 15 of whom were referred for surgery. US was made with a real-time linear-array scanner, provided with a transducer of 7.5 MHz. Subsequently, all patients underwent single-contrast arthrography of the shoulder. When compared with the arthrographic findings, diagnosis by US showed 21 true positive, 3 false positive, 57 true negative and 7 false negative cases of a full-thickness tear of the rotator cuff. Small tears (2 cm or less in diameter) may be the most difficult to assess. US readily revealed biceps tendinitis and rupture of the biceps tendon, as well as fluid collection in the bursae above the rotator cuff tendons.

Surgical repair of the rotator cuff and surrounding tissues. Factors influencing the results.

The surgical pathology and clinical results of 78 reconstructions of chronic rotator cuff tears were reviewed retrospectively. The predominant complaint preoperatively was chronic pain with impaired shoulder function, resistant to repeated conservative treatment. Results according to a functional assessment were excellent or satisfactory in 71% of the patients, unsatisfactory in 12%, and failed in 17%. Relief of pain including night pain and pain with activity was obtained. Surgery should include a thorough exploration of the rotator cuff and the adjacent tissues. Accompanying problems, including biceps tendon disorders or impingement factors, must be recognized and treated at the time of the reconstruction procedure. Repair of the torn rotator cuff and treatment of concomitant lesions are effective operative procedures when symptoms are persistent and fail to respond to conservative treatment.

Arthrography of the biceps tendon.

The purpose of this study was to analyse the factors having an influence on the arthrographic imaging of the biceps tendon. The study comprised 174 patients suffering from chronic shoulder pain. They underwent conventional shoulder arthrography with sodium meglumine metrizoate or metrizamide as a contrast medium. In the patients with a full-thickness tear of the rotator cuff, the biceps tendon sheath failed to fill with contrast medium more often than in those with an intact tendinous cuff. Metrizamide filled the biceps tendon sheath more readily than sodium meglumine metrizoate in patients with a full-thickness tear of the rotator cuff. The volume of the contrast medium injected had no influence on the imaging of the biceps tendon.

Evans' procedure in the treatment of chronic instability of the ankle.

During the period 1979-1983, 34 patients were treated for chronic instability of the ankle which was confirmed by stress radiography, using Evans' procedure. Of the injuries, 65 per cent were sustained at sport. A feeling of instability was the main presenting symptom (85 per cent). All the patients were examined clinically and with stress radiography at follow-up. The results were regarded as good in 27 cases (80 per cent), fair in five (14 per cent) and poor in two cases. None of the patients found the limitation of subtalar inversion disturbing. In the radiographic examination using a Cheuba stress-producing device, the magnitude of anterior drawer instability as well as the talar tilt was significantly reduced (P less than 0.001).

Immobilization leads to early changes in hydrostatic pressure of bone and joint. A study on experimental osteoarthritis in rabbits.

Immobilization of a rabbit leg in extension results in the early development of an aseptic inflammation, synovial effusion and stiffening, and subsequent osteoarthritis of the knee. To study the pathogenesis of this experimental osteoarthritis, the hydrostatic pressures were measured in the knee, and distal metaphysis and diaphysis of the femur, after different periods of immobilization in 28 rabbits and eight control rabbits. A marked rise in pressure was registered early in the femoral metaphysis, diaphysis and especially in the knee. The maximal pressures were found after two days of immobilization in the metaphysis and seven days in the knee. During the next two weeks the pressures decreased slowly towards the normal values. These changes were related to the thickening and stiffening of the knee. The increased pressure in the bone and joint may be an important pathogenetic factor in the experimental osteoarthritis following immobilization. Measurements of the hydrostatic pressure may be a valuable parameter aiding the development of better preventive and curative methods in arthritis and osteoarthritis.

Spinal block, after dantrolene pretreatment, for resection of a thigh muscle herniation in a young malignant hyperthermia susceptible man.

We describe a young man who experienced malignant hyperpyrexia, probably triggered by suxamethonium and/or enflurane during his second operation for an epigastric hernia. His malignant hyperthermia susceptibility was later verified using the caffeine/halothane contracture test in vitro. Subsequently, a tumorous mass, consisting of herniated and hypertrophied muscle grew in his thigh, and was resected under spinal anaesthesia. Whereas dantrolene (2.5 mg/kg i.v.) pretreatment produced impaired swallowing, the subsequent high spinal block, in addition, resulted in laboured breathing. It is stressed that respiratory power should be monitored when patients pretreated with dantrolene are given spinal anaesthesia. The muscular symptoms and test results in the patient's relatives are also discussed.

The intraarticular pressure during shoulder arthrography. A diagnostic aid in rotator cuff tear.

The intraarticular pressure was determined in 24 shoulders during glenohumeral joint arthrography. As the contrast volume increased, the pressure stayed low in the shoulders with a tear of the rotator cuff and rose along a characteristic biphasic curve in intact shoulders. Simultaneous monitoring of the intraarticular pressure can improve the diagnostic value of arthrography.

A double-blind crossover evaluation of naproxen and piroxicam in osteoarthritis of hip or knee.

Seventy-five patients participated in a randomized, double-blind, crossover study, the aim of which was to compare the efficacy and safety of naproxen 1000 mg once daily with piroxicam 20 mg once daily for the treatment of osteoarthritis of hip or knee. Treatment periods of 4 weeks each were preceded by placebo wash-out periods of up to 1 week. The patients were examined clinically at every stage of the trial. Each treatment group exhibited significant improvement in weight-bearing and night pain, over-all disease severity, and the separate evaluations of patient response by physician and patient. There were no significant differences between the drugs in type, severity, or number of side-effects. Neither of the drugs influenced the patients' laboratory data. Night pain was less for patients using naproxen than for those taking piroxicam, and patients indicated greater preference for naproxen than for piroxicam. Naproxen was statistically superior to piroxicam as measured by decreased weight-bearing pain and over-all disease severity, the separate physician and patient global assessments of patient response to therapy, and physician preference. In this study, naproxen 1000 mg once daily was more effective than piroxicam 20 mg once daily for the treatment of osteoarthritis.

Recurrent anterior dislocation of the shoulder. Results of Eden-Hybbinette and Putti-Platt operations.

The results of surgery in 74 cases of recurrent anterior dislocation of the shoulder are reported. The procedures used were Eden-Hybbinette (E-H) in 48 cases and Putti-Platt (P-P) in 26 cases. The recurrence rate in the 62 shoulder joints re-examined some 4 years postoperatively was 3/41 in E-H cases and 3/21 in P-P cases. The clinical results were excellent in 46 cases, satisfactory in 11, unsatisfactory in four and poor in one case without notable difference between the methods. A restriction of the outward rotation of more than 10 degrees could be observed in half the cases regardless of method. Radiographically, the Bankart lesion of the glenoid rim could be observed in two-thirds of the cases and osteoarthrosis of the glenohumeral joint was evident in one tenth. The transplanted bone block used in the E-H reconstruction was still in position in the majority but some degree of resorption could usually be observed. These observations did not correlate with the clinical results.

Operative treatment of severe proximal humeral fractures.

Results after the operative treatment of 41 severe proximal fractures of the humerus are reported. The fractures were classified according to Neer (1970a). The aim of treatment was accurate reduction and stable fixation of the fracture with screws or with screws and a plate. When scored according to Neer's (1970a) functional assessment, results in the 31 patients re-examined more than 1 year postoperatively were excellent or satisfactory in 23 patients. Results were excellent or satisfactory in 14/15 patients with type III fractures, in 7/11 with IV, and 2/4 with type VI. In the only re-examined patient with a type V fracture the result was unsatisfactory. The most common technical error was a too high positioning of the AO plate and persistent varus deformation of the head of the humerus. High positioning of the plate caused post-operative restriction in the movements of the glenohumeral joint because the implant impinged under the acromion during abduction. No aseptic necrosis of the humeral head was observed. Of the patients of working age all but one returned to their preoperative occupations within a mean of 3.5 months after surgery.