Reliability and validity of surface EMG assessments combined with isometric muscle strength testing in patients with abdominal rectus diastasis and asymptomatic controls.

PURPOSE: Patients with abdominal rectus diastasis (ARD) may have muscular functional impairments, but clinics lack appropriate objective assessment tools. The aim was to establish the relative and absolute reliability, and convergent validity, of muscular activity using Surface Electromyography (SEMG) during isometric abdominal muscle strength testing in patients with ARD and controls without ARD. METHODS: Twenty-six patients with ARD were matched for age, sex and BMI with controls without ARD. Participants were tested twice during isometric muscular contractions using SEMG located on six abdominal sites. Mean amplitude, fatigue, and recruitment order were analyzed. Relative reliability was evaluated with Intraclass Correlation Coefficients (ICC), while absolute reliability was estimated by calculating the Standard Error of Measurement and Minimal Detectable Change. Convergent validity was addressed in relation to participant characteristics, functional ability, and symptoms. RESULTS: Mean SEMG amplitude for all abdominal wall muscle contractions showed moderate to excellent relative test-retest reliability, with ICC values ranging from 0.46 to 0.97. In contrast, fatigue and recruitment order displayed poor to moderate relative reliability in both groups. Absolute reliability measures were generally high. A moderate to high convergent validity (ARD: rho-value 0.41-0.70; Controls: rho-value 0.41-0.75) was observed for mean amplitude in relation to a functional sit-to-stand test, abdominal circumference, BMI, back pain, and quality-of-life. CONCLUSIONS: The results of applying SEMG during isometric abdominal muscle support practicing the method in clinics, although additional development is needed with further standardization and more functional testing. Furthermore, the method demonstrates construct validity in patients with ARD and in age- and sex-matched controls.

A virtual reality trauma simulator.

The authors have evaluated a trauma simulator based on virtual reality techniques. Ten surgeons and 15 medical students performed distal locking of a femoral nail (A). Furthermore, 10 medical students performed simulated osteosynthesis of a femoral neck fracture (B). Total surgery time (A) (mean value) was shorter for surgeons (108 s) compared with students (157 s) at the first (p = 0.033), second (102 respectively 138 s, p = 0.13) and third (96 respectively 160 s, p = 0.15) operation. Total fluoroscopy time (A) (mean value) was shorter for surgeons compared with students at the first (45 respectively 89 s, p = 0.001), second (48 respectively 83 s, p = 0.02) and third (50 respectively 107 s, p = 0.10) operation. The positioning of the hip nails (B) improved between the first and last trial. Total surgery and fluoroscopy time were reduced. All participants thought that this and similar simulators should be part of the programme and that this simulator would be helpful if they were about to learn the procedures.

Health-related quality of life after osteoporotic fractures.

OBJECTIVE: To estimate the impact of osteoporosis fractures on health-related quality of life (HRQOL) in postmenopausal women. METHODS: To compare the impact on HRQOL of different osteoporotic fractures, 600 consecutive women 55-75 years old with a new fracture (inclusion fracture) were invited by mail. After exclusions by preset criteria (high-energy fractures, ongoing osteoporosis treatment, or unwillingness to participate), 303 women were included, 171 (56%) of whom had a forearm, 37 (12%) proximal humerus, 40 (13%) hip, and 55 (18%) vertebral fracture, respectively, and all were investigated and treated according to the current local consensus program for osteoporosis. In addition, HRQOL was evaluated by the SF-36 questionnaire and compared with local, age-matched reference material. Examinations were performed 82 days (median) after the fracture and 2 years later. RESULTS: HRQOL was significantly reduced at baseline regarding all SF-36 domains after vertebral fractures and most after hip fractures, but only regarding some domains after forearm and humerus fracture. After 2 years, improvements had occurred after all types of fractures, and after forearm or humerus fracture, HRQOL was completely normalized in all domains. However, 2 years after hip fracture, HRQOL was still below normal regarding physical function, role-physical and social function, while after vertebral fracture, scores were still significantly lower for all domains, physical as well as mental. Patients with one or more previous fractures before the inclusion fracture had lower HRQOL at baseline and after 2 years, compared with those with no previous fracture. Patients with osteoporosis (T-score <-2.5 in hip or spine) had lower HRQOL than those with normal BMD. CONCLUSION: Vertebral and hip fractures have a considerably greater and more prolonged impact on HRQOL than forearm and humerus fractures. The number of fractures was inversely correlated to HRQOL. These differences should be taken into account when making priorities in health care programs.

Heterotopic ossification following internal fixation or arthroplasty for displaced femoral neck fractures: a prospective randomized study.

One hundred hips in 99 patients of 75 years or older, with a displaced femoral neck fracture, were studied for heterotopic ossification (HO). The patients were randomized to either internal fixation or total hip arthroplasty (THA). In the THA group HO was found in 32 of 45 hips compared with 1 of 39 in the internal fixation group (P < 0.0012). The frequency of HO after THA corresponds well with findings in other studies on patients receiving THA for osteoarthrosis. In cervical fractures the surgical procedure of total hip replacement seems to be a prerequisite for HO, indicating that the procedure itself is more important than the patient's age and the diagnosis. Severe symptoms due to HO were found in only one patient. HO following THA for a femoral neck fracture is of little clinical importance and prophylaxis is unnecessary.

Monitoring referral and treatment in soft tissue sarcoma: study based on 1,851 patients from the Scandinavian Sarcoma Group Register.

This report is based on 1.851 adult patients with soft tissue sarcoma (STS) of the extremities or trunk wall diagnosed between 1986 and 1997 and reported from all tertiary referral centers in Norway and Sweden. The median age at diagnosis was 65 years and the male-to-female ratio was 1.1:1. One third of the tumors were subcutaneous, one third deep, intramuscular and one third deep, extramuscular. The median size was 7 (1-35) cm and 75% were high grade (III-IV). Metastases at presentation were diagnosed in 8% of the patients. Two thirds of STS patients were referred before surgery and the referral practices have improved during the study. The preoperative morphologic diagnosis was made with fine-needle aspiration cytology in 81%, core-needle biopsy in 9% and incisional biopsy in 10%. The frequency of amputations has decreased from 15% in 198688 to 9% in 1995-1997. A wide surgical margin was achieved in 77% of subcutaneous and 60% of deep-seated lesions. Overall, 24% of operated STS patients had adjuvant radiotherapy. The use of such therapy at sarcoma centers increased from 20% 1986-88 to 30% in 1995-97. Follow-up has been reported in 96% of the patients. The cumulative local recurrence rate was 0.20 at 5 years and 0.24 at 10 years. The 5-year metastasis-free survival rate was 0.70.

Local recurrence of deep-seated, high-grade, soft tissue sarcoma: 459 patients from the Scandinavian Sarcoma Group Register.

This study was based on 459 adult patients with deep, high-grade, soft tissue sarcoma of extremities or trunk wall reported to the Scandinavian Sarcoma Group Register (1986-1993). All patients had their definitive surgery for primary tumor at a sarcoma center. The median follow-up was 7.5 (3-12) years. 204 patients are still alive. 68 patients had amputations and 391 underwent limb-sparing surgery. Among 183 patients with intralesional or marginal margins after limb-sparing surgery, 65% had postoperative radiotherapy and 9% of the 198 patients with wide margins. The local recurrence rate after limb-sparing surgery was 26%. The rate with an intralesional or marginal margin was 39% without postoperative radiotherapy versus 24% when radiotherapy was given. It was 25% after a wide margin, and no recurrences were noted among the 10 patients with a compartmental surgical margin. Among patients with a wide margin, a subset fulfilling criteria for a myectomy was defined. The local recurrence rate was 26% among these 62 and there was no advantage of myectomy over other wide margins. More radical surgical margins would improve the local recurrence rate, but this can hardly be achieved in center-operated patients without increasing the amputation rate. Instead, increased use of radiotherapy in all patients with inadequate margins, and to a larger extent in those with wide margins will improve local control.

Nutritional status and functional capacity after femoral neck fractures: a prospective randomized one-year follow-up study.

The primary aim of this study was to evaluate the effect of two different surgical methods on nutritional status and functional capacity during the first postoperative year in patients with displaced femoral neck fractures. A further aim was to evaluate the effect of nutritional support. One hundred patients were randomly assigned to treatment with either primary total hip arthroplasty (THA) or osteosynthesis. Half of the patients in each treatment group received protein- and energy-enriched food in the hospital in addition to individual nutritional advice in order to optimize their intake of protein- and energy-rich food. Nutritional state and functional capacity were examined at baseline, one and three months, and one year after the operation. Pain was examined at three months and one year. The effect of nutritional intervention was equal within both surgical groups. Logistic regression showed that the dependent variable "living at one year" was significantly associated with serum albumin levels at one month. Advanced age, mental impairment and deteriorated nutritional status were predominant in the non-survivors. Overall, the primary THA group performed better compared with the osteosynthesis group concerning weight change over time, locomotion and pain. This study also showed that primary THA could safely be performed in the elderly without an increased postoperative mortality rate.

Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips.

100 patients 75 years or older, with displaced femoral neck fractures, were randomly assigned to osteosynthesis with two parallel and percutaneously inserted screws (Olmed) or total hip arthroplasty (Lubinus IP). Mean age was 84 (75-101) years, 74% were women and 45% had mental dysfunction. General complications were commoner in the arthroplasty group but the mortality rates did not differ. In the osteosynthesis group, fracture complications were seen in 27/50 hips. In the arthroplasty group, dislocation was the main complication and occurred in 11/50 cases. At 3 months and after 1 year, the Harris Hip Scores were significantly better in the arthroplasty group. When mental dysfunction was present, the dislocation rate after arthroplasty was 32%, whereas the reoperation rate after osteosynthesis was 5%. The opposite pattern of complications was found in patients with normal mental function, 12% versus 60%. The 2-year mortality rate among those with mental dysfunction was 26/45, compared to 7/55 of those with normal function (p < 0.001). We conclude that total hip arthroplasty should be considered for a displaced femoral neck fracture in old patients with normal mental function and high functional demands.

Consequences of local recurrence of soft tissue sarcoma: 205 patients from the Scandinavian Sarcoma Group Register.

From the Scandinavian Sarcoma Group Register, information on 1,224 surgically-treated patients with soft tissue sarcoma (STS) of the extremity or trunk wall, diagnosed between 1987 and 1995, was collected. 205 patients, one third of whom were referred to a center with a local recurrence, had a total of 284 local recurrences. This analysis describes the treatment for these local recurrences, complications and risk of further recurrences. 169 patients were surgically treated for their first local recurrence. An intralesional or marginal margin was achieved in 110 of these patients, 59 of whom were also given radiotherapy. 54 of the 169 patients had a second local recurrence. The second local recurrence rate was 0.50 if the first local recurrence had been treated with only surgery with a marginal margin, compared to 0.28 if treated with surgery with a marginal margin and radiotherapy or with a wide margin (p = 0.0008). In extremity STS, the crude amputation rate for local recurrences was 0.22 (31 of 142)-i.e., higher than for primary tumors 0.09 (96 of 1065) (p < 0.0001). A high local recurrence rate after treatment outside of sarcoma centers has earlier been shown. We conclude that the consequences of local recurrence in terms of morbidity and costs justifies referral of STS patients for multidisciplinary evaluation and multimodality treatment.

Clinical course in synovial sarcoma: a Scandinavian sarcoma group study of 104 patients.

We analyzed treatment and outcome in 104 Scandinavian patients with synovial sarcoma in the extremities or trunk wall, diagnosed between 1986 and 1994. Only surgically treated patients without metastases at diagnosis were included. Median follow-up of survivors was 6 (3-11) years. 34 patients developed metastases. The overall 5- and 7-year survival rates were 0.76 (95% CI 0.66-0.83) and 0.69 (0.58-0.78), respectively. Large tumor size and amputation were significantly associated with impaired metastasis-free survival. Patients with local recurrence had a higher risk of metastases following the local event. Local excision with inadequate margin was associated with a higher risk of local recurrence.

Constant region of a kappa III immunoglobulin light chain as a major AL-amyloid protein.

AL-amyloidoses are generally described as a group of disorders in which N-terminal fragments of monoclonal immunoglobulin light chains are transferred into amyloid fibrils. We have, by amino acid sequence analyses and immunological methods, characterized the Bence-Jones protein and the corresponding AL protein as a kappa III immunoglobulin light chain from material of a patient with systemic AL-amyloidosis presenting as a local inguinal tumour. The two proteins showed some unique features. The major part of the AL amyloid fibril protein consisted of C-terminal fragments of the Bence-Jones protein. Furthermore, both the Bence-Jones protein and the AL protein were glycosylated, with possibly a glycosylation in the constant part of the light chain.

Multiprofessional education in the medical curriculum.

The aim of this project was to design a programme for the students at the Faculty of Health Sciences (FHS) which has long fostered multiprofessional education, and encourages development of positive attitudes and skills related to collaboration with other health professionals. This should be characterized by mutual respect and understanding and should also provide students with insight into the various professional roles and competencies involved in collaboration within the health care system. A multi-professional training ward, and since January 1996 a student-manned training ward, has been in operation at the Department of Orthopaedics, University Hospital, Linköping. The care, treatment and rehabilitation of patients is performed by students from all the education programmes at the FHS. While the supervisors are medically responsible, they generally only observe and provide guidance without taking too much active part in the practical work. The students are recruited during one of their last two semesters when they have attained fairly good insight into their future professional roles. Experience thus far has shown that a training ward seems to be a very efficient way of improving the ability to work as a team with real patients, and is an inspiring and efficient means for obtaining these skills which, in turn, are essential in future professional work. This paper reports the implementation and first experiences of the training ward. A detailed evaluation of the effects of an educational ward, taking into account the opinions and attitudes of students, teachers and patients, is in progress.

Twenty-year results of McKee-Farrar versus Charnley prosthesis.

The results of 107 consecutive McKee-Farrar and 70 Charnley total hip arthroplasties performed in 169 patients between 1975 and 1976 are reviewed. At an average followup of 20 years (range, 19-21 years), 29 patients with 20 McKee-Farrar and 11 Charnley prostheses were available for clinical and radiologic evaluation; 102 patients (107 hips) had died, 3 patients were lost to followup, and 5 patients (6 hips) were unavailable for review because of medical problems. There were 5 revisions for sepsis and 1 Girdlestone procedure for recurrent dislocation. Sixteen McKee-Farrar and 8 Charnley prostheses were revised for aseptic loosening, giving a 20-year aseptic probability of survival of 77% and 73%, respectively. Radiographic signs of loosening were present in 52% of the surviving prostheses. Clinical scores showed weak correlation with the radiographic loosening in both groups, and 18 McKee-Farrar and 8 Charnley prostheses were still considered satisfactory by the patients. The mean annual linear polyethylene wear was 0.12 mm. Osteolytic lesions were observed in association with 2 McKee-Farrar and 5 Charnley prostheses in surviving hips. The long term results of the McKee-Farrar prosthesis are comparable with those of the low friction arthroplasty in this series. Wear of the polyethylene bearing and accumulation of polyethylene particles in the periprosthetic tissue may become an increasing problem. Second generation all metal implants seem to be worth considering in patients with long life expectancy.

Stem loosening more common with ITH than Lubinus prosthesis. A 5-year clinical and radiographic follow-up of 142 patients.

Out of a consecutive series of 169 cemented total hip arthroplasties, 77 Lubinus SP 2 and 65 ITH prostheses, were followed-up after 5 years with clinical and radiographic assessments. Radiolucencies were commoner around the ITH titanium stem than around the Lubinus cobalt-chrome stem. 6 of the ITH stems were considered as definitely loose, as compared to none of the Lubinus stems. Hitherto, 5 patients in the ITH group have had revisions and 2 need revision because of loosening. The poorer performance of the cemented ITH stem may be due to an unfavorable combination of design and material properties.

The effect of low dose diclofenac sodium administered locally on heterotopic bone formation in rats.

The effect of a low dose of diclofenac sodium, administered locally, on heterotopic bone formation in rats was investigated. Heterotopic bone was induced by implantation of demineralised bone matrix into the gluteal muscles. Diclofenac was released continuously for 2 weeks from micro-osmotic pumps for each demineralised bone implant in the rats. Each had a control implant in the opposite gluteal muscle to which saline was released in the same way. The yield of new woven bone was determined after 4 weeks by measuring the ash-weights of the implants. Those of the diclofenac samples were significantly decreased compared to the controls. These results suggest that a low dose of diclofenac given locally decreases heterotopic bone formation in rats.

Effect of diclofenac on fixation of hydroxyapatite-coated implants. An experimental study.

We studied the effect of non-steroidal anti-inflammatory drugs on the fixation of hydroxyapatite-coated implants. Cylindrical plugs of pure titanium, coated with hydroxyapatite (HA), were inserted into both femora of 10 adult rabbits, 5 of which received 7 daily doses of 30 mg diclofenac. Three weeks after implantation the interface strengths were measured by the pull-out test. The mean peak force for the diclofenac-treated group was 290 +/- 57 N compared with 369 +/- 37 N for the control group (p < 0.025). We conclude that the inhibitory effect of diclofenac on bone repair is not neutralised by HA-coating of an implant.

Revision of infected hip replacement. Two-stage procedure with a temporary gentamicin spacer.

We revised 5 infected totally-replaced hips in 2 stages. At the first operation a gentamicin-loaded modelled cement spacer was inserted, and the definitive prosthesis was inserted 3-8 weeks later. 9-24 months after the last operation, there was a recurrent infection in 1 case. 2 of the patients could walk in the interval.

Renal function after hip arthroplasty and isoxazolylpenicillin prophylaxis.

Two different isoxazolylpenicillins (cloxacillin and dicloxacillin) were compared regarding impairment of renal function after total hip arthroplasty. 85 patients received dicloxacillin and 93 patients received cloxacillin as antibiotic prophylaxis. A total dose of 6 grams was given during a 36-hour period in doses of 1 gram pre-, per- and postoperatively. Creatinine in serum and beta 2-microglobulin in serum and urine were determined preoperatively and 2, 4, and 10 days after the operation. The dicloxacillin-treated patients had an increase in creatinine and beta 2-microglobulin in serum that was not seen in the cloxacillin group. The increase indicates a transient injury in the process of glomerular filtration. Although the increase was temporary and subclinical, a dose reduction is nevertheless recommended for older patients.