The effect of subcutaneous nerve stimulation (SCNS) on pain associated with osteoarthritis of the hip.

A novel form of subcutaneous nerve stimulation (SCNS) was recently introduced for the relief of chronic pain. We present a study using this form of SCNS applied over the radial, median and saphenous nerves in patients with clinically diagnosed osteoarthritis of the hip. Acceptable pain relief was obtained in 60% of patients receiving stimulation, however, comparable analgesia was achieved in a control group, who received no electrical stimulation through similarly placed needles. We suggest that these results may be explained by the ability of SCNS to evoke a placebo response. The efficacy of the placebo effect and the ethical implications of its use in clinical practice are discussed.

Long-term results of partial undercutting facetectomy for lumbar lateral recess stenosis.

STUDY DESIGN: A retrospective review of 57 consecutive patients who had a partial undercutting facetectomy for degenerative lumbar lateral recess stenosis between 1983 and 1988. OBJECTIVES: To evaluate the long-term results of this procedure. SUMMARY OF BACKGROUND DATA: Few studies have been published on the long-term outcome of decompression for lumbar stenosis. Most studies have included central as well as lateral recess stenosis and have not differentiated between the two. Furthermore, no study has looked at the long-term results of partial undercutting facetectomy. METHODS: All patients were assessed by standard questionnaire, clinical examination, and radiography by an independent observer. The minimum follow-up period was 5 years (mean, 8.4 years). RESULTS: Overall, 72% had no leg pain, 16% had some leg pain needing occasional analgesia, and 12% had severe leg pain needing continual analgesia. CONCLUSIONS: The long-term results of partial undercutting facetectomy are very satisfying.

A prospective study of nerve root infiltration in the diagnosis of sciatica. A comparison with radiculography, computed tomography, and operative findings.

Fifty nerve root infiltration studies were evaluated prospectively in a consecutive series of 50 patients referred to the Sheffield Problem Back Clinic with complicated back problems. All were over 35 years of age (mean, 51 years). Ten (20%) demonstrated abnormal segmentation of the lumbar spine. Sixteen (32%) had undergone previous surgery. Before nerve root infiltration all patients were investigated by radiculography and computed tomography. Nerve root infiltration identified two types of response. In 20 patients, infiltration reproduced the symptomatic pain, which then was abolished by local anesthetic--the positive result. These patients were considered suitable for surgery. One patient in this group had spontaneous resolution of pain and thus did not undergo operative treatment. In 30 patients, infiltration did not reproduce the symptomatic pain regardless of the level studied, or only partially reproduced the pain at two or more levels--the negative result. Radiculography and computed tomography in these patients also was inconsistent. This group were considered unsuitable for surgery. In those patients undergoing surgical decompression, nerve root infiltration correctly identified the symptomatic level in 18 of the 19. Computed tomography and radiculography identified the level in 14 and 12 patients, respectively.

The evaluation of liquid crystal thermography in the investigation of nerve root compression due to lumbosacral lateral spinal stenosis.

The role of liquid crystal thermography (LCT) in the investigation of nerve root compression due to lumbosacral lateral spinal stenosis was evaluated using a quantitative analysis technique. In 28 healthy volunteers, normal lower limb dermatomal asymmetry was found to follow a Gaussian distribution, with a normal range of less than 1.0 degree for the lower limbs and less than 1.9 degrees for the feet. The results of LCT from a patient group were compared with those from other investigations, with the following results: clinical assessment (107 patients), 53% agreement; myelography (60 patients), 45% agreement; computerized tomography (35 patients), 46% agreement; electromyography (27 patients), 41% agreement; and surgical findings (19 patients), 53% agreement. Each method of investigation was compared against the surgeon's final overall assessment. Clinical assessment agreed in 76%, myelography in 71%, computerized tomography in 71%, and electromyography in 70%. However, agreement could be demonstrated in only 48% of cases using LCT; therefore, it would appear that LCT is by far the least reliable of these techniques in the diagnosis of nerve root compression.

Compensation, work status, and disability in low back pain patients.

STUDY DESIGN: A prospectively designed study was performed to assess the influence of employment status and a compensation claim on patients experiencing low back pain. OBJECTIVES: To determine the factor that most influences disability arising from low back pain, unemployment or a compensation claim. SUMMARY OF BACKGROUND DATA: Two hundred sixty-nine consecutive patients were assessed from a low back pain clinic. METHODS: Disability was assessed using the Oswestry Disability Score, and employment, and compensation status were recorded. RESULTS: Both unemployment and patients involved in compensation had higher disability scores. However, by controlling the data for employment and assessing only the compensation group it was found that those claiming compensation, but still working had significantly less disability than those claiming compensation who were unemployed. CONCLUSIONS: Both unemployment and compensation claims influence disability, but employment status is the most important factor.

Lumbar spinal stenosis: the clinical spectrum and the results of operation.

Thirty-one patients who had been treated surgically for lumbar spinal stenosis between 1968 and 1978 at the Norfolk and Norwich Hospital have been personally reviewed. In 28 patients (90 per cent) degenerative change in the lumbar spine had been the principal aetiological factor; the other three had idiopathic developmental lumbar spinal stenosis. In 17 patients (55 per cent) the result was classified as good, although a total of 26 patients (84 per cent) were satisfied. In patients with degenerative changes, one important reason for failure was inadequate decompression; re-operation in this group seemed worthwhile. The good results of operation for lumbar spinal stenosis were characterised by rapid resolution of pain in the leg.

Simultaneous or staged bilateral total knee replacements in rheumatoid arthritis. A prospective study.

In a prospective study of 100 knee arthroplasties in patients with rheumatoid arthritis, simultaneous bilateral surgery was compared with staged bilateral replacements. All patients had improved function following their operations but those who had staged surgery only achieved maximum benefit after the second knee had been replaced. The complication rate was no greater for simultaneous surgery and we therefore advocate the method for those patients who require bilateral replacements.

Exchange arthroplasty for infected knee replacements. A new two-stage method.

We report a series of 17 exchange arthroplasties for infected knee prostheses, ten one-stage and seven two-stage procedures. The method proved successful in controlling infection and restoring function. In two-stage exchanges the interval between the stages was managed by using a prosthesis as a spacer, and acrylic cement beads containing the appropriate antibiotic to provide high local concentrations. Three one-stage procedures had recurrence of infection, but were successfully treated by further exchange operations. All patients had satisfactory function and there have been no serious complications. We recommend this modified two-stage technique for the management of infected knee arthroplasties.

Anterior knee pain in rheumatoid patients after total knee replacement. Possible selection criteria for patellar resurfacing.

Postoperative anterior knee pain was evaluated in a consecutive series of 138 knees in 108 patients with rheumatoid arthritis treated by total knee replacement with Mark I Insall-Burstein prostheses. No knee had primary patellar resurfacing, and in the 119 knees followed up for a mean of 63.9 months, none had secondary resurfacing. Anterior knee pain was absent in 87 knees (73%), mild in 16 (13.5%) and moderate or severe in 16 (13.5%). The height of the patella above the prosthetic joint line was the only variable which was directly related to the incidence of anterior knee pain. The sensitivity and specificity of patellar height measurements for identifying patients with or without pain were derived. From these data, a selective policy of resurfacing the patella in those at risk was adopted. Choosing a patellar height of 15 mm or less, patellar resurfacing could be avoided in 80% of patients likely to have no pain, and the patella could be resurfaced in 65% of those likely to have anterior knee pain.

The importance of the valgus hindfoot in forefoot surgery in rheumatoid arthritis.

The relationship between hindfoot deformity and forefoot pressure was assessed in 28 rheumatoid patients who had undergone forefoot reconstruction four years previously. Patients with valgus hindfoot deformities tended to have high forefoot pressures whereas those with a normal hindfoot recorded normal pressures on the dynamic pedobarograph. All patients with residual forefoot pain recorded abnormal forefoot pressures. We believe that orthotic control of hindfoot deformities should be considered for those patients who require forefoot surgery as a combination of surgical and orthotic management may offer the best chance of success.

Tibial dysplasia. A study of the anatomy.

Three amputated legs with tibial dysplasia were studied by radiography, arteriography and anatomical dissection. The radiographic appearances were the same as the Type 1b tibial dysplasia described by Jones, Barnes and Lloyd-Roberts (1978) in that the tibiae were absent but the lower femoral epiphyses were normal. However, our anatomical findings differed from those of Jones et al. since no bony or cartilaginous anlage of the proximal tibia was found in any of the three legs. The pattern of vascular anomaly was identical in the three legs and similar to the findings of Hootnick et al. (1980) in congenital short fibula. Congenital fusion of the subtalar joint was a constant finding. These results support the hypothesis that the arterial and skeletal systems are vulnerable to a teratogenic insult in the fifth week of embryonic life. The bony and arterial anomalies should be borne in mind by the surgeon attempting reconstructive surgery for this condition.

Partial undercutting facetectomy for bony entrapment of the lumbar nerve root.

Seventy-eight patients who had been operated on for bony entrapment of lumbar nerve roots were studied in an attempt to define the clinical syndrome, and to assess the results of a new technique of decompression which preserves spinal stability. The mean age of the patients was 45 years and 28 of them had previously undergone spinal operations. Pain in the leg was the predominant symptom, with evidence of motor involvement in half of the patients. Signs of nerve root tension were found in only one-third of the patients. The principal factor in the aetiology was degenerative change in the posterior facet joints. Decompression was achieved by a partial undercutting facetectomy. Fifty-nine per cent of the patients obtained a "good" result and 85 per cent were satisfied with the result of their operation. Successful partial facetectomy for bony entrapment of lumbar nerve roots produced rapid and lasting relief of pain.

The Stanmore total elbow replacement for rheumatoid arthritis.

Between 1970 and 1982, 50 total elbow replacements were carried out for rheumatoid arthritis using the Stanmore prosthesis. A long-term follow-up of the 44 elbows available for review is presented. Thirty-four of these (77%) had good results, five were fair, and five were poor. The complications and limitations are discussed.

Wrist arthrodesis in rheumatoid arthritis. A comparison of two methods of fusion.

17 wrists were arthrodesed in 13 patients with severe wrist disease due to rheumatoid arthritis. Eight fusions in seven patients were carried out using a radial sliding bone graft technique whilst nine fusions in nine patients were undertaken using a third tubular AO plate. Subjective, objective and radiological assessments confirmed the efficacy of both methods but indicated a shorter period of post-operative immobilization for patients treated using the AO plate fixation technique. The importance of this is discussed.

"Bony sciatica"--the value of thermography, electromyography, and water-soluble myelography.

With an increased interest in sporting activity, particularly among the older population, together with the appreciation of the importance of "bony entrapment" as a cause of sciatica, so the need has arisen to develop a simple, noninvasive, reliable, and reproducible method of determining whether leg pain is of radicular or referred origin. In our experience, liquid crystal thermography has proved unsatisfactory but electromyography appears to be of value in distinguishing root from referred pain in approximately 70 per cent of patients within this group. Our experience with radiculography within this context is also presented and is shown to be currently unsatisfactory.

Acute compartment syndrome following revisional arthroplasty of the forefoot: the dangers of ankle-block.

A case of acute compartment syndrome of the forefoot after revisional arthroplasty of the forefoot is presented. Shortening of the compartments due to bony resection and extensive dissection due to previous scarring may have predisposed to the pathological condition. Prompt decompression based on clinical grounds prevented any long term sequelae. Allowance must be made for the concomitant use of local anaesthetic procedures which may obscure the clinical picture.

The Pipkin fracture-dislocation of the hip.

The 'Pipkin' fracture-dislocation of the hip is an injury that is easily missed and is associated with serious sequelae. Eighty posterior dislocations of the hip were studied; there were nine 'Pipkin' injuries, seven of which are reported. The aetiology and management is discussed and the literature is reviewed. Guidelines for management are suggested.

The knee after midshaft femoral fracture treatment: a comparison of three methods.

A retrospective study of knee function has been carried out in 85 patients who had fractures of the midshaft of the femur treated by three currently used methods. Patients who had undergone open medullary fixation, skeletal traction with early knee movements, and skeletal traction with an immobile knee have been compared. All the patients were reviewed personally, with a mean follow-up time of 5 years. We found that 30 per cent of all the patients had minor knee symptoms, and nearly half (45 per cent) had some ligamentous laxity. When bony union resulted, there was no difference in the effect on knee function between the three methods of treatment. Neither skeletal traction nor early knee movement had a harmful effect on the knee in the absence of any major ligamentous injury.

Acute volar compartment syndrome of the forearm secondary to fractures of the distal radius.

We present five cases of acute volar compartment syndrome developing as a complication of fractures of the distal radius. The patients were all males under the age of 50 years who sustained comminuted or displaced fractures of the distal radius. We suggest that this indicates an 'at risk' group. The interval between injury and the onset of symptoms of volar compartment syndrome varied between 12 and 48 hours. The diagnosis of each case was made clinically and confirmed at operation. With early extensive decompression full neurovascular recovery can be expected.

Disseminated intravascular coagulation in elective primary total hip replacement.

Acute disseminated intravascular coagulation is a common and potentially serious complication of many clinical conditions, including trauma. We report two cases in which this condition occurred after routine elective primary total hip replacement.