Pre-operative pain management with nerve block in patients with hip fractures: a randomized, controlled trial

INTRODUCTION

Pain management in patients with hip fractures is a major challenge for emergency care. The objective of this study was to evaluate whether the supplementation of pre-operative analgesia with low-dose fascia iliaca compartment block (FICB) compared with placebo would improve pain relief in patients with hip fractures.

METHODS

A double-blind, randomized, controlled trial was conducted on 127 patients. At hospital admission, a low-dose FICB was administered to patients with hip fractures as a supplement to regular pre-operative analgesia. Patients with and without cognitive impairment were included. The instruments used were a visual analogue scale (VAS), a numerical rating scale and a tool for behavior related pain assessment. The primary endpoint was the change in reported pain on movement from hospital admission to two hours after FICB.

RESULTS

The intervention group showed improved pain management by mean VAS score for pain on movement compared with the control group (p = 0.002).

CONCLUSIONS

Our results support the use of low-dose FICB as a pain-relieving adjuvant to other analgesics when administered to patients with a hip fracture.

Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up

BACKGROUND

Treatment options for irreparable cuff tears include synthetic interposition grafts, but whether such grafts can maintain acceptable shoulder function and prevent cuff tear arthropathy in the long-term is unknown.

METHOD

This was a retrospective case series of 13 consecutive patients treated with a synthetic interposition graft made of Dacron (DuPont, Wilmington, DE, USA). Patients were examined with bilateral ultrasonography, bilateral x-ray imaging, Constant-Murley score, and Western Ontario Rotator Cuff score.

RESULTS

After a mean of 18 years (range, 17-20 years), 1 patient had died, and 12 were available for x-ray imaging and 10 also for ultrasonography and clinical scores. Cuff tear arthropathy (Hamada grade ≥2) had developed in 9 of 12 (75%; 95% confidence interval, 43%-95%), including 3 patients operated on with arthroplasty in the follow-up period. The mean absolute Constant-Murley score was 46 (standard deviation, 26), and the mean Western Ontario Rotator Cuff score was 59 (standard deviation, 20). In 7 of 10 patients (70%) with available ultrasonography, the graft was interpreted as not intact. All patients had a contralateral full-thickness tear, and 7 of 12 patients (58 %; 95% confidence interval, 28%-85%) had contralateral cuff tear arthropathy. The number of patients with cuff tear arthropathy was not significantly different between the shoulder repaired with a Dacron graft and the contralateral shoulder (P = .667).

CONCLUSION

These results indicate that a synthetic interposition graft with screw fixation could not prevent cuff tear arthropathy and preserve cuff integrity in a long-term perspective.

Clinical and structural outcome 22 years after acromioplasty without tendon repair in patients with subacromial pain and cuff tears

BACKGROUND

Long-term results regarding tear progression, arthropathy, and clinical scores of unrepaired rotator cuff tears are largely unknown. This study investigated whether the condition of the glenohumeral joint and rotator cuff had deteriorated at a minimum of 20 years after an acromioplasty without cuff repair and assessed the clinical results.

METHODS

A retrospective analysis was conducted of a consecutive series of patients treated between 1989 and 1993 with acromioplasty without cuff repair due to subacromial pain and cuff tear. At follow-up results of x-ray, ultrasonography, and clinical scores were recorded.

RESULTS

At a mean of 22 years (range, 21-25 years), 69 patients were available for follow-up with Western Ontario Rotator Cuff Index, Constant-Murley (CM) score, x-ray, and ultrasonography. Mean age at operation was 49 years (range, 19-69 years). There were 45 partial-thickness tears (PTT) and 24 full-thickness tears (FTT). Of 23 patients with FTT, 17 (74% with x-ray) had developed cuff tear arthropathy (Hamada ≥2) and 20 (87% with ultrasonography) had progressed in tear size. Mean relative CM in patients with FTT and cuff tear arthropathy was 62 (standard deviation [SD], 27), and the mean WORC was 58% (SD, 26%). In the 43 PTT patients, 3 (7% with x-ray) had developed cuff tear arthropathy and 16 (42% with ultrasonography) had tear progression. With PTT at follow-up, the mean relative CM was 101 (SD, 22), and the mean WORC was 81% (SD, 20%).

CONCLUSIONS

After an acromioplasty, most unrepaired full-thickness tears will, in long-term, increase in size and be accompanied by cuff tear arthropathy changes. Most partial thickness tears remain unchanged; cuff tear arthropathy is rare, and clinical scores generally good.

Development of physical performance after acute hip fracture: an observational study in a regular clinical geriatric setting

BACKGROUND AND AIM

Hip fracture is a leading cause of mortality, morbidity, and disability in older people. The aim of the present study was to prospectively assess the development of physical performance in patients with hip fracture after surgery.

SETTING

Prospective, observational study in a Swedish university hospital.

METHODS

Assessment of 102 consecutive patients (65 females), with a mean age of 82 years (range 35-98) without specific inclusion or exclusion criteria. Seven physical functions were assessed using the following 4 measuring methods and 3 rating scales at baseline 7 to 10 days after surgery and follow-up after 4 months (F4): 10-m habitual walking speed (HWS), timed up and go (TUG), 30-second chair stand test (CST), handgrip strength (HGS), Berg balance scale (BBS), functional ambulation category (FAC), and general mobility.

RESULTS

The 47% dropout patients were significantly older and more often lived alone or in nursing homes and used indoor walking aids. At baseline, the mean HWS was 0.4/0.5 (females/males) m/s; TUG 53/30 s; CST 4/5 kg, and HGS 17.4/31.2 kg. The medians of BBS and FAC were 20/20 and 4/4, respectively. There were significant mean improvements at F4 for all 4 measured functions, except for HGS in males but for neither of the rating scales. There was a large heterogeneity in all assessed variables, both at baseline and regarding change at 4 months. Therefore, the mean/median results are depicted in figures, showing all individual results at baseline and F4, compared to reference values and discussed in relation to degree of improvement.

CONCLUSION

The observed large heterogeneity at baseline as well as F4 makes it essentially meaningless to report means and median data of functional assessment of patients with hip fracture. There is a strong need for individualization in both health analysis and how the treatment program is targeted, carried through, and evaluated over time in patients with hip fracture.

Sever's injury: a clinical diagnosis

BACKGROUND

The diagnosis of Sever's injury (apophysitis calcanei) has previously been partly based on radiographic findings in the calcaneal apophysis. Sclerosis and fragmentation have been supposed to represent signs of inflammation due to tractions from the Achilles tendon. The clinical findings, diagnostic criteria, and studied population are often poorly defined. We sought to define diagnostic criteria by analyzing clinical and radiographic characteristics in a population with Sever's injury and to compare the findings with those of a control group of matched, symptom-free children.

METHODS

We assessed 30 consecutive children with Sever's injury with high levels of pain but high physical activity levels in sports activities and 15 pain-free matched controls.

RESULTS

One-leg heel standing showed 100% sensitivity; the squeeze test, 97%; and the palpation test, 80%. All three tests showed 100% specificity. All of the patients and controls showed increased density of the apophysis. Half of the pain-free controls showed fragmentation versus almost 90% of children with heel pain.

CONCLUSIONS

The diagnosis of Sever's injury is clinical, not radiologic. Radiologic findings of increased density and fragmentation are found also in pain-free controls with high levels of physical activity and may, therefore, represent normal growth and development. We suggest that the diagnosis of Sever's injury should be based on patient history and the results of two specific clinical tests.

Intermittent versus indwelling urinary catheterisation in hip surgery patients: a randomised controlled trial with cost-effectiveness analysis

BACKGROUND

Hip surgery is associated with the risk of postoperative urinary retention. To avoid urinary retention hip surgery patients undergo urinary catheterisation. Urinary catheterisation, however, is associated with increased risk for urinary tract infection (UTI). At present, there is limited evidence for whether intermittent or indwelling urinary catheterisation is the preferred choice for short-term bladder drainage in patients undergoing hip surgery.

OBJECTIVES

The aim of the study was to investigate differences between intermittent and indwelling urinary catheterisation in hip surgery patients in relation to nosocomial UTI and cost-effectiveness.

DESIGN

Randomised controlled trial with cost-effectiveness analysis.

SETTING

The study was carried out at an orthopaedic department at a Swedish University Hospital.

METHODS

One hundred and seventy hip surgery patients (patients with fractures or with osteoarthritis) were randomly allocated to either intermittent or indwelling urinary catheterisation. Data collection took place at four time points: during stay in hospital, at discharge and at 4 weeks and 4 months after discharge.

RESULTS

Eighteen patients contracted nosocomial UTIs, 8 in the intermittent catheterisation group and 10 in the indwelling catheterisation group (absolute difference 2.4%, 95% CI -6.9-11.6%) The patients in the intermittent catheterisation group were more often catheterised (p<0.001) and required more bladder scans (p<0.001) but regained normal bladder function sooner than the patients in the indwelling catheterisation group (p<0.001). Fourteen percent of the patients in the intermittent group did not need any catheterisation. Cost-effectiveness was similar between the indwelling and intermittent urinary catheterisation methods.

CONCLUSIONS

Both indwelling and intermittent methods could be appropriate in clinical practice. Both methods have advantages and disadvantages but by not using routine indwelling catheterisation, unnecessary catheterisations might be avoided in this patient group.

The influence of age, delay of repair, and tendon involvement in acute rotator cuff tears: structural and clinical outcomes after repair of 42 shoulders

BACKGROUND AND PURPOSE

Few authors have considered the outcome after acute traumatic rotator cuff tears in previously asymptomatic patients. We investigated whether delay of surgery, age at repair, and the number of cuff tendons involved affect the structural and clinical outcome.

PATIENTS AND METHODS

42 patients with pseudoparalysis after trauma and no previous history of shoulder symptoms were included. A full-thickness tear in at least 1 of the rotator cuff tendons was diagnosed in all patients. Mean time to surgery was 38 (6-91) days. Follow-up at a mean of 39 (12-108) months after surgery included ultrasound, plain radiographs, Constant-Murley score, DASH score, and western Ontario rotator cuff (WORC) score.

RESULTS

At follow-up, 4 patients had a full-thickness tear and 9 had a partial-thickness tear in the repaired shoulder. No correlation between the structural or clinical outcome and the time to repair within 3 months was found. The patients with a tendon defect at follow-up had a statistically significantly lower Constant-Murley score and WORC index in the injured shoulder and were significantly older than those with intact tendons. The outcomes were similar irrespective of the number of tendons repaired.

INTERPRETATION

A delay of 3 months to repair had no effect on outcome. The patients with cuff defects at follow-up were older and they had a worse clinical outcome. Multi-tendon injury did not generate worse outcomes than single-tendon tears at follow-up.

A heel cup improves the function of the heel pad in Sever's injury: effects on heel pad thickness, peak pressure and pain

Sever's injury (apophysitis calcanei) is considered to be the dominant cause of heel pain among children between 8 and 15 years. Treating Sever's injury with insoles is often proposed as a part of a traditional mix of recommendations. Using a custom-molded rigid heel cup with a brim enclosing the heel pad resulted in effective pain relief without reducing the physical activity level in our previous two studies. The purpose of this study was to assess the effect of the heel cup on heel pad thickness and heel peak pressure (n=50). The difference in heel pad thickness and in heel peak pressure using a sports shoe without and with a heel cup was compared. With the heel cup the heel pad thickness improved significantly and the heel peak pressure was significantly reduced. These effects correlated with a significant reduction in pain when using the heel cup in a sports shoe, compared with using a sports shoe without the heel cup. A heel cup, providing an effective heel pad support in the sports shoe, improved the heel pad thickness and reduced heel peak pressure in Sever's injury with corresponding pain relief.

Sever's injury; treat it with a heel cup: a randomized, crossover study with two insole alternatives

Sever's injury (apophysitis calcanei) is considered to be the dominant cause of heel pain among children. Common advice is to reduce physical activity. However, our previous study showed that application of insoles reduced pain in Sever's injury without having to reduce physical activity. The purpose of this study was to test which of the two insoles, the heel wedge or the heel cup, provided best pain relief during sport activity in boys with Sever's injury (n=51). There was a crossover design in the first randomized part of the study. In the second part, the boys, 9-14 years, chose which insole they preferred. There was a reduction in odds score for pain to a fifth (a reduction of 80%) for the cup compared with the wedge (P<0.001). When an active choice was made, the heel cup was preferred by >75% of the boys. All boys maintained their high level of physical activity throughout. At 1-year follow-up, 22 boys still used an insole and 19 of them reported its effect on pain as excellent or good (n=41).

Sever's injury: treatment with insoles provides effective pain relief

Sever's injury (apophysitis calcanei) is considered to be the dominant cause of heel pain among children between 8 and 15 years. The traditional advice is to reduce and modify the level of physical activity. Recommended treatment in general is the same as for adults with Achilles tendon pain. The purpose of the study was to find out if insoles, of two different types, were effective in relieving heel pain in a group of boys (n=38) attending a Sports Medicine Clinic for heel pain diagnosed as Sever's injury. The type of insole was randomized, and self-assessed pain during physical activity in the treatment phase with insoles was compared with pain in the corresponding pre- and post-treatment phases without insoles. There were no other treatments added and the recommendations were to stay on the same activity level. All patients maintained their high level of physical activity throughout the study period. Significant pain reduction during physical activity when using insoles was found. Application of two different types of insoles without any immobilization, other treatment, or modification of sport activities results in significant pain relief in boys with Sever's injury.

Fewer rotator cuff tears fifteen years after arthroscopic subacromial decompression

BACKGROUND

A successful clinical result is reported in 75% to 85% of impingement patients after arthroscopic subacromial decompression. The result is maintained over time, but few studies have investigated the integrity of the rotator cuff in these patients.

MATERIALS AND METHODS

Using ultrasonography, we examined the integrity of the rotator cuff in 70 patients 15 years after arthroscopic subacromial decompression. All patients had an intact rotator cuff at the index procedure.

RESULTS

Tendons were still intact in 57 patients (82%), 10 (14%) had partial-thickness tears, and 3 (4%) had full-thickness tears.

DISCUSSION

The total number of 18% tears (partial and full thickness) in this study, including patients clinically diagnosed with subacromial impingement at a mean age of 60 years, is unexpectedly low compared with 40% degenerative tears reported in asymptomatic adults of the same age.

CONCLUSION

Arthroscopic subacromial decompression seems to reduce the prevalence of rotator cuff tears in impingement patients. This appears attributable to elimination of extrinsic factors such as mechanical wear and bursitis. The potential effect of surgery on intrinsic cuff degeneration is unknown, but intrinsic factors may explain tears still developing despite decompression.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Small full-thickness tears do well ten to thirteen years after arthroscopic subacromial decompression

A consecutive series of 181 patients with clinical signs of subacromial impingement underwent arthroscopic subacromial decompression (ASD). All patients had the same surgical procedure, and all pathological findings at the arthroscopy were recorded. Ten to 13 years (mean, 11.2) after the procedure, 162 patients (91%) were available for follow-up consisting of clinical examination and the Constant-Murley and DASH scores. The overall mean value of the age correlated Constant score was 77 points. Men had significantly better Constant score than women. The state of the rotator cuff at the index procedure was found to affect the outcome significantly. Patients with isolated full-thickness supraspinatus tears had the best results, followed by those with partial tears, intact cuffs, or large tears involving more than 1 tendon. ASD in the treatment of subacromial impingement yields good long-term results. Small full-thickness supraspinatus tears had the best results, indicating that the ASD might prevent further cuff deterioration and that repair of these lesions may be unnecessary.

Intramedullary cancellous screw fixation for nonunion of midshaft clavicular fractures

6 patients with symptomatic nonunion of midshaft clavicular fractures were treated by internal fixation with an intramedullary cancellous screw and autologous cancellous bone grafting. At follow-up after median 21 (12-72) months, all nonunions had healed. The Constant score was median 98 (57-100) points. 1 patient, with shortening of the clavicle, had poor function.

Fibronectin, MMP-1 and histologic changes in rotator cuff disease

This study was designed to investigate human surgical specimens from patients with impingement (n = 16), ruptured supraspinatus tendons (n = 7), frozen shoulder (n = 2) and controls (n = 9) with respect to histological changes and the presence of fibronectin and Matrix metalloprotease-1 (MMP-1). The biopsy of the middle part of the supraspinatus tendons was analyzed microscopically after staining with hematoxyline eosin, Van Giesons hematoxyline and Phospho Tungstic Acid Hematoxyline for visualization of fibrin. Immunofluorescent stainings for fibronectin and MMP-1 were performed. Histology and immunofluorescence were assessed blindly. Necrotic tendinous tissue and fibrin were found only in some specimens from ruptures. The staining for fibronectin was significantly increased among patients with a rupture. MMP-1 was, however, only infrequently found in specimens from patients with impingement and ruptures. Fibrosis and thinning of fascicles seemed to be a more non-specific finding, appearing in control, impingement and rupture specimens. In conclusion, necrotic tendinous tissue, fibrin and fibronectin appear to be signs of tendon degeneration, whereas fibrosis and thinning of fascicles were found also in controls.

Intraoperative measurements of the subacromial distance

PURPOSE

The purpose of this study was 2-fold: to document the accuracy of a new measuring device and to intraoperatively compare the subacromial distance between controls and patients with impingement syndrome before and after arthroscopic subacromial decompression (ASD).

TYPE OF STUDY

Clinical study.

METHODS

When performing an ASD, it is important that bone resection is adequate. Today the correct subacromial distance after bone resection is only assessed by eye, directly or indirectly. The subacromial distance was measured between the anterolateral corner of the acromion and the supraspinatus tendon in the lateral decubitus position. The device was inserted 2 to 3 cm below the anterolateral acromion. There was no subacromial pathology among the controls (n = 15, mean age, 28 years). In 30 patients with impingement syndrome (average age, 53 years) an ASD was performed. The subacromial distance was measured after bursectomy and then after bone resection. Intraindividual and interindividual assessment was performed.

RESULTS

The mean value of the subacromial distance in controls was 16 mm, the 95% confidence limits between 14 and 18 mm. The mean value in the group of patients with impingement syndrome was 8 mm before and 16 mm after the decompression. Due to the pressure within the subacromial space, the subacromial distance increased 1 mm. Intraindividual measurements never varied more than 1 mm (n = 5). The correlation coefficient between the measurements by both authors was 0.99.

CONCLUSIONS

In this study, we assessed and described the use of a measuring device that enables the surgeon to quantify the subacromial distance before and after bone resection. After bone resection, the mean value of the subacromial distance was well within the control values. The amount of bone resected varied from 5 to 13 mm. This new device enables documentation in clinical work as well as in research.

Injury incidence and prevalence among elite weight and power lifters

The purpose of this study was to investigate the incidence and prevalence of injuries among elite weight lifters and power lifters, with a special focus on shoulder injuries and possible injury-provoking exercises. In 1995, a questionnaire was administered to 110 male and female elite lifters to evaluate injuries and training characteristics. A follow-up of the athletes from 1995 was conducted in 2000, and a new 2000 elite group was also queried. In 1995 and again in 2000, the athletes sustained, on average, 2.6 injuries per 1000 hours of activity. Most common in 1995 were low back injuries, with an injury rate of 0.43 per 1000 hours, and shoulder injuries, with a rate of 0.42 per 1000 hours. Shoulder injuries dominated in 2000, with an injury rate of 0.51 per 1000 hours of activity. There was a difference in injury pattern between weight lifters, who mostly sustained low back and knee injuries, and power lifters, in whom shoulder injuries were most common. No correlation was found between shoulder injuries and any specific exercise. Although the total injury rate was the same during the two periods of study, the rate of shoulder injuries had increased.

Intraoperative measurement of shoulder translation

Assessing laxity of the shoulder joint in patients who are under anesthesia is a standard procedure before arthroscopy. The aim of this study was to evaluate a novel instrument for quick and reliable intraoperative measurement of glenohumeral translation. Previous testing of various designs has resulted in a device secured by 1 pin in the acromion and 1 pin in the proximal humerus. These pins are interconnected by a sliding ruler that gives translation values in millimeter increments as the laxity tests are performed. Comparison between manual arbitrary approximation of laxity and instrumented translation measurements showed that manual testing is reasonably good for assessment of anterior and posterior translation, without, however, providing values of translation in millimeter increments. The low correlation between manual assessment and instrumented inferior translation measurements indicates that inferior translation is more difficult to approximate manually. The shoulder translation tester was used in 102 patients. The mean values for clinically stable shoulders (n = 58) were 5 mm for anterior translation, 5 mm for posterior translation, and 4 mm for inferior translation. The corresponding values in unstable shoulders were significantly higher than in the stable shoulders, especially in patients with multidirectional instability. We conclude that the shoulder translation tester is easy and quick to use. It provides quantitative values of translation and will thus contribute information for correct diagnosis, therapy, and documentation.

Carrageenan-induced subacromial bursitis caused changes in the rat's rotator cuff

This study was designed to investigate the histologic expression of the rat's supra- and infraspinatus tendons in carrageenan-induced subacromial bursitis. Thirty-two rats received subacromial injections with carrageenan (n = 28) or saline (n = 4). The tendons were analysed microscopically after staining with hematoxyline eosin, Van Giesons hematoxyline and immunofluorescent staining of fibronectin and fibrinogen. In the controls (saline x 10) and group A (carrageenan x 5) there were no changes in the tendons. In group B (carrageenan x 10) 3/8 rats showed macrophages between the collagen fibres and an increased staining of fibronectin. In group C (double dosis carrageenan) all rats had signs of fibrocartilaginous metaplasia in the supraspinatus tendon. In eight of these specimens even bony metaplasia was seen. The infraspinatus tendon showed fibrosis but no fibrocartilaginous metaplasia. The results showed that iatrogenic bursitis after carrageenan subacromial injections was associated with marked changes of the supraspinatus tendon.

Outcome after cup hemiarthroplasty in the rheumatoid shoulder: a retrospective evaluation of 39 patients followed for 2-6 years

33 rheumatoid patients, treated with hemispherical cup resurfacing hemiarthroplasty of the shoulder without medullary fixation (6 bilaterally), were reviewed after mean 4.4 (2-6) years. The median Constant score was 30 (15-79), mean proximal migration of the humerus 55 (SD 5.2) mm and mean glenoid erosion 2.6 (SD 1.7) mm. Proximal migration and glenoid erosion did not correlate with shoulder function or pain. Radiographic signs of loosening (changes in cup inclination combined with changes in cup distance above the greater tuberosity) occurred in one quarter of the shoulders. At follow-up, 26 patients were satisfied with the procedure, despite poor shoulder function and radiographic deterioration.

The influence of cuff pathology on shoulder function after arthroscopic subacromial decompression: a 3- and 6-year follow-up study

In the literature operative management of rotator cuff ruptures in the shoulder varies, from tendon repair to debridement of the cuff lesion combined with subacromial decompression. This study was made to evaluate whether patients with intact rotator cuff differed from patients with rotator cuff ruptures regarding functional outcome after arthroscopic subacromial decompression. We performed a clinical review of 39 patients with subacromial impingement who all underwent arthroscopic subacromial decompression; no other surgery was performed. There were 13 patients with intact cuff, 13 patients with partial-thickness supraspinatus ruptures, and 13 patients with full-thickness supraspinatus ruptures < 2 cm. Selection was based solely on the status of the supraspinatus tendon. Patients with other pathologic conditions were excluded. Follow-up was performed after 3 and 6 years. The clinical evaluation was performed with the Constant score and the visual analog pain score. The 3- and 6-year follow-up (100% follow-up rate) revealed no significant difference between the groups regarding the Constant scores and the visual analog scale values. Also, no significant difference was seen among the 3 groups in active range of motion or strength, and the patients had no appreciable pain. We conclude that the functional outcome 6 years after arthroscopic subacromial decompression is not obviously related to the preoperative degree of cuff pathology, even if a total rupture of small size is present.

Effect of steroid injections on the rotator cuff: an experimental study in rats

The aim of this study was to evaluate the effects of repeated steroid injections into the subacromial space. Thirty rats were injected either 3 or 5 times with triamcinolone in a dosage equivalent to that given to human beings or 3 or 5 times with saline into the subacromial space. One rat received no injection. The supraspinatus and infraspinatus tendons were evaluated macroscopically and microscopically. Two different staining methods were used on each sample including hematoxylin eosin and Miller's elastin/van Gieson's solution. After 5 steroid injections, we found focal inflammation, necrosis, and fragmentation of collagen bundles in the tendon in 4 of 7 rats. The tendons of the controls showed a normal structure (P < .05). There were no pathologic changes among the rats that were injected with triamcinolone 3 times. These results show that repeated subacromial injections of triamcinolone may cause damage to the rotator cuff of the rat. This finding may indicate cautious use of subacromial steroid injections in human beings.

The clinical effect of ketoprofen after arthroscopic subacromial decompression: a randomized double-blind prospective study

The purpose of the study was to evaluate the clinical effect of ketoprofen after arthroscopic subacromial decompression (ASD). The design was randomized, prospective, and double-blind, with a placebo control group. Forty-one consecutive patients with subacromial impingement syndrome, were randomized to treatment with ketoprofen 200 mg once daily or placebo for 6 weeks following ASD. For additional analgesia, patients used paracetamol if necessary. Clinical follow-up was performed at 6 weeks and at 2 years postoperatively. At the 6-week follow-up, the patients treated with ketoprofen had a statistically significant increase in UCLA total score (P<.05), range of movement (P<.05), and satisfaction (P<.05), and they had significantly less pain (P<.05). There was no statistical difference between the ketoprofen and placebo groups regarding strength. Patients receiving ketoprofen had significantly less need for additional analgesia (P<.05). At the 2-year follow-up, there were no differences in the scores between the ketoprofen and placebo group.

Multidirectional hyperlaxity of the shoulder: results of treatment

We have evaluated the results after rehabilitation and compared this to inferior capsular shift in patients with multidirectional hyperlaxity (MDH). The patients (n=35) experienced either instability and/or pain. We divided the patients into two groups: one group (group A) included patients with MDH and only pain but no symptoms of instability (n=6). All these patients had initial rehabilitation, followed by surgery in four cases. None of the patients with only pain (n=6) were satisfied after rehabilitation. Only two out of four were satisfied after surgery. In the second group (group B) were included patients who had MDH with both pain and instability. Six patients had surgery without prior rehabilitation and 20 patients had initial rehabilitation. Eight of these patients had surgical stabilization after unsuccessful rehabilitation. Less than half of the patients with MDH and instability (n=20) were satisfied after rehabilitation alone. Twelve of 14 patients were satisfied after surgery. We conclude that patients with MDH and only pain are difficult to treat. Patients with MDH and instability respond only moderately to the exercise program. Surgery, in combination with physiotherapy, should be the initial treatment when instability is the main symptom.

Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study

Two hundred and forty-five patients who had had 247 primary anterior dislocations of the shoulder were followed for ten years in a multicenter study at twenty-seven Swedish hospitals. The ages of the patients at the time of the dislocation ranged from twelve to forty years. The patients were assigned to one of three treatment groups: immobilization with the arm tied with a bandage to the torso for three to four weeks after reduction of the dislocation; use of a sling, which was discontinued after the patient was comfortable; or immobilization for various durations. At the ten-year follow-up evaluation, no additional dislocation had occurred in 129 shoulders (52 per cent). Recurrent dislocation necessitating operative treatment had developed in fifty-eight shoulders (23 per cent): thirty-four (34 per cent) of the ninety-nine shoulders in patients who were twelve to twenty-two years old, sixteen (28 per cent) of the fifty-seven shoulders in patients who were twenty-three to twenty-nine years old, and eight (9 per cent) of the ninety-one shoulders in patients who were thirty to forty years old. Twenty-four (22 per cent) of the shoulders that had had at least two recurrences during the first two or five years seemed to have stabilized spontaneously without operative intervention at ten years. Dislocation of the contralateral shoulder occurred in association with sixteen (16 per cent) of the ninety-nine shoulders in patients who were twelve to twenty-two years old, twelve (21 per cent) of the fifty-seven shoulders in patients who were twenty-three to twenty-nine years old, and only three (3 per cent) of the ninety-one shoulders in patients who were thirty to forty years old. The type and duration of the initial treatment had no effect on the rate of recurrence. Radiographs, made for 185 shoulders at the time of the primary dislocation, demonstrated an evident Hermodsson (Hill-Sachs) lesion in ninety-nine shoulders (54 per cent); this finding was associated with a significantly worse prognosis with regard to recurrence than was no evident lesion (p < 0.04). Radiographs made for 208 shoulders at the ten-year follow-up examination were evaluated for post-dislocation arthropathy. Twenty-three shoulders (11 per cent) had mild arthropathy and eighteen (9 per cent) had moderate or severe arthropathy. Some of the shoulders that had arthropathy had had no recurrence.

Ankle performance after ankle fracture: a randomized study of early mobilization

In a prospective, randomized study, 30 patients were evaluated after ankle fracture treated by means of open reduction and internal fixation. The patients were randomized to either postoperative immobilization in a plaster cast for 6 weeks or early mobilization (1-2 weeks after surgery) in an ankle brace. Both regimens allowed weightbearing. Evaluation after 10 weeks and after 12 months included clinical assessment and isokinetic muscle strength measurements. Patients with impaired ankle function, as shown by means of an ankle score at 12 months, were followed for 3 years. At 10 weeks, impaired muscle torque and restricted range of motion was found on the affected side. This impairment was significantly less in the brace group. At 12 months, range of motion of the ankle and subtalar joints was restored, but dorsiflexion was still better in the brace group. Score values from a functional score did not correlate with muscle strength.

Use of Mitek anchoring for Bankart repair: A comparative, randomized, prospective study with traditional bone sutures

The most common type of shoulder instability is posttraumatic anterior instability. Treatment is surgical. Of the several procedures used, the standard one is Bankart repair. However, this procedure is technically demanding. To simplify it a suture anchor such as Mitek anchors may be used. A prospective randomized study was conducted to compare Mitek anchors with bone sutures. The results showed that Mitek anchors shorten surgical time by making reattachment of the capsule easier. Shoulder muscle strength, range of motion, and frequency of recurrence were equally good in the anchor group and bone suture group. A roentgenographic method allowed exact measurement of placement of the anchors. This method showed at 2-year follow-up evaluation that the anchors were still in the anterior glenoid. No metal-related complications are found at the 2-year follow-up evaluation.

Shoulder region of the rat: anatomy and fiber composition of some suprascapular nerve branches

BACKGROUND

The pathophysiology of chronic supraspinatus tendinitis is not fully understood. This may be due to the scarcity of experimental studies on this issue.

METHODS

In search for a system suitable for experimental analysis, the present study describes the relevant gross anatomy of the rat shoulder region (dissection), and examines the fiber composition of relevant supra-scapular nerve branches (electron microscopy, selective denervations).

RESULTS

The rat shoulder region is similar to the human shoulder in terms of gross anatomy. The average suprascapular nerve (SSC) is derived mainly from the spinal cord segment C5 and contains 3,435 axons, 74% of which are unmyelinated. The supraspinatus branch (SSP) contains 627 fibers. Of the SSP fibers, 52% are myelinated, including 32% motor and 20% sensory axons. Of the C-fibers in the SSP 16% are sympathetic efferents and 32% are sensory. Many of the latter disappear after neonatal capsaicin treatment. The SSC emits a subacromial articular branch (ART), with some 260 axons, about 90% of which are unmyelinated. The myelinated ART fibers are sensory, and of the unmyelinated ones about 24% are sympathetic efferents and 66% are afferents. The latter resist neonatal capsaicin treatment.

CONCLUSIONS

In view of the anatomy of the supraspinatus muscle, of the subacromial space, and of relevant nerves, the rat shoulder should be appropriate for experimental studies on inflammatory conditions in the subacromial space.

Intraarticular pathology in acute, first-time anterior shoulder dislocation: an arthroscopic study

Intraarticular soft tissue damage after first-time, acute shoulder dislocation has been poorly described in the literature. The present study describes 24 cases of first-time anterior shoulder dislocation that all were evaluated under anesthesia and examined via arthroscopy. All shoulders sustaining anterior dislocation show Bankart and Hill-Sachs lesions. They also show anterior instability. The arthroscopic findings were uniform and therefore cannot be used as predictors for future development of recurrent instability.

Arthroscopic subacromial decompression versus open acromioplasty. A two-year follow-up study

In a prospective study, 20 patients were randomly selected for either open acromioplasty according to Neer or for arthroscopic subacromial + decompression (ASD). All suffered from shoulder impingement for which conservative treatment had been unsuccessful. Functional results after two years were assessed. All patients were assessed radiographically to visualize recurrence of subacromial osteophytes. Functional results in the arthroscopic group are good and similar to those after open surgery. Both methods seem to result in adequate subacromial decompression, including bone resection. The arthroscopic method also has in its favor less operating time, earlier restoration of active range of motion, and reduction in time away from work.

One session surgery on the lower limb in children with cerebral palsy. A five year follow-up

Twenty three children with cerebral palsy, who were operated on upon before 1984, have been re-assessed. All the lower limb deformities were corrected in one surgical session. Review after five years included foot-switch measurements and assessment of video recordings. There were no recurrences, and gait ability showed normal growth-related development.

Anti-hepatitis C virus screening will reduce the incidence of post-transfusion hepatitis C also in low-risk areas

The incidence of post-transfusion hepatitis non-A, non-B (PTH-NANB) was prospectively assessed in two areas in the southeast region of Sweden. Patients undergoing hip arthroplasty were studied with blood sampling for alanine aminotransferase analysis before and at 2, 3, and 4 months after transfusion. Of the patients 97% and 82% were transfused and received a mean of 5.5 and 3.4 units in Linköping and Oskarshamn, respectively. None of 38 patients in Oskarshamn but 4 of 144 patients (2.8%) in Linköping contracted PTH-NANB. Two of these four patients developed antibodies against hepatitis C virus (HCV) by the first-generation anti-HCV enzyme-linked immunosorbent assay (ELISA) (C100). The other two patients remained negative by this test. HCV infection was, however, indicated in all four patients by positive second-generation anti-HCV ELISA confirmed by positive second-generation recombinant immunoblot assay (4-RIBA). Three of the patients were positive by polymerase chain reaction (PCR). Serum from one blood donor to the four hepatitis patients (altogether three donors) was found positive by first- and second-generation anti-HCV ELISA and 4-RIBA and was also PCR-positive. Three other blood donors, who did not transmit hepatitis, were anti-HCV ELISA (C100)-positive. This study shows that if anti-HCV ELISA had been available at the start of the trial, all cases of PTH would have been avoided at the expense of only 0.7% transfusion units discarded. Routine anti-HCV ELISA testing of all transfusion units will reduce the incidence of PTH-C even in low-risk areas.

The natural history of Perthes' disease

Since 1975, none of our patients with Perthes' disease have received any active treatment, except for managing severe pain. We have studied the functional and radiological results in order to evaluate the consequences of this approach and to demonstrate the natural history of the disease. We have followed up all patients over the age of 19 years; out of 20 only 6 were free of pain and only 2 reached 100 points on the Iowa hip score. Radiographs at follow up demonstrated that no involved hip had a spherical femoral head. We conclude that our passive attitude towards Perthes' disease results in relatively few patients having good hip function, especially when compared with the results of other authors. Active treatment, including operation, is probably more successful.

Short-term cefotaxime prophylaxis reduces the failure rate in lower limb amputations

The effect of prophylaxis with a broad-spectrum antibiotic agent in lower limb amputations was studied in a prospective, randomized investigation of 38 patients. Nineteen received cefotaxime (Claforan) and 19 served as controls. Three patients died in the immediate post-operative period. In the treatment group, 15/18 healed compared with 10/17 controls (P less than 0.001). We concluded that short-term cefotaxime prophylaxis increases the chances to achieve good stump healing.

Arthroscopic subacromial decompression versus open acromioplasty

A random prospective comparison was conducted of 20 patients who underwent arthroscopic subacromial decompression or open acromioplasty as treatment for impingement syndrome. The Neer anterior acromioplasty served as comparison in the evaluation to arthroscopic technique. The comparison shows more rapid rehabilitation and better range of motion in the arthroscopic group. Time of surgery is also shorter for arthroscopy than for the open technique. Arthroscopic subacromial decompression appears to be superior to open acromioplasty as a treatment for impingement syndrome.

Development of gait in spastic children with cerebral palsy

The gait of 50 spastic children 3-16 years old was recorded and analyzed. All children showed abnormal values of both basal parameters and phases of the stride. In gait velocity and stride length, their values were lower than normal, but they increased with age, with stride length increasing in parallel with normal values. Stride frequency showed a decrease with age, the reverse of normal. Stance and swing, when normalized with regard to stride duration, showed no change with age in spastic children. Also, stance was longer than in normal children, the same tendency as shown by double support. Hemiplegic children showed clearly asymmetric phases. The decreasing stride frequency with increasing age indicates a relative slowing of movements. Most changes with age were, however, the same as in normal children. The prolonged stance and double support suggest deteriorated postural control, resulting in an increased need of support.

Changes in gait patterns after operations in children with spastic cerebral palsy

We have utilised a scoring system with the aid of a specially designed worksheet to measure gait ability in spastic children with cerebral palsy before and after corrective soft tissue operations. Postoperatively, there were obvious improvements in gait especially in the mobility of the leg and the foot. Comparison between a visually assessed score and objectively recorded values using foot-switches showed a good correlation. The postoperative improvement was most obvious in hemiplegic children, but was also present in diplegic children following both single and complex one-stage operations.

The effect of corrective surgery on energy expenditure during ambulation in children with cerebral palsy

Mechanical efficiency, heart rate, blood lactate, and some other variables were studied in six children with cerebral palsy who walked on a treadmill before and after corrective surgery. During each test, conducted at each child's naturally selected speed, two situations were studied: steady state level walking for 9 min, and then walking at an increasing inclination up to 20% for another 10 min. During the test the subjects were allowed to hold on to a handrail to eliminate the risk of falling off the treadmill. The corrective surgery resulted in a 5% reduction in oxygen consumption per kg body mass during level walking. The subjects' levels of physical fitness, as estimated from oxygen pulse, however, were unchanged. These results are indicative of a biomechanical improvement due to the corrective surgery. While walking at a 20% inclination the subjects off loaded themselves to different degrees on the handrail which influenced the results. Their feeling of exhaustion at this load was probably due to local factors, since heart rate was well below maximal values, and blood lactate, respiratory exchange ratio and ventilatory equivalent also indicated that they were below their anaerobic thresholds (50-60% of maximal oxygen uptake).

One-session surgery for correction of lower extremity deformities in children with cerebral palsy

Traditional thinking regarding surgery for the spastic child has favored correction of joint deformities one at a time. This often necessitates several operations. In addition, deformities of unoperated joints may jeopardize operative results. Since 1975, we have surgically treated all the lower extremity deformities of each cerebral palsied child in one session. We have carried out single measure operations as well as multiple operative procedures in which bilateral corrective operations are performed on several joints. Of 114 children treated, 40 had multiple and 74 had single operative procedures. Treatment was successful, without need for further surgery, in 80% of the former group and in 61% of the latter. The advantages of one-session surgery are a reduction in the number of operations and, possibly, a reduced chance of reoperation and complications.

Development of gait in the normal child

Gait patterns of 230 normal children, 3 to 16 years old, were studied with the aid of footswitches. They walked in three different requested velocities. Velocity, stride length, cadence, and the temporal phases of the stride were recorded along with leg length of the subjects. These gait parameters change with age, and the changes are most pronounced up to 8 to 10 years. Thereafter, only minor changes take place and leg length becomes the dominating factor.