Björn M. Persson

Aspiration cytology of soft-tissue tumors: The 10-year experience at an Orthopedic Oncology Center

Since 1972, we have included fine-needle aspiration cytology in the pre-operative evaluation of soft tissue lesions referred to our Orthopedic Oncology Group. In 365 consecutive patients the cytodiagnosis was correctly malignant in 66/74 tumors and correctly benign in 260/271 lesions; cytology was non-diagnostic in four sarcomas and 16 benign lesions. The final pre-operative diagnosis should be based on all pre-operative data to minimize the effect of any misjudgement as regards cytodiagnosis; only two of the 19 false cytodiagnoses were of consequence for the patient. We conclude that aspiration cytology used in this way is a valuable adjunct to determine the further management of soft tissue tumors.

Increased Incidence of Lower Limb Amputation for Arterial Occlusive Disease

The number of amputations in Malmöhus county with just over 500 000 inhabitants had increased from 14 to 161 during the years 1910-79 measured each fifth year comprising totally 724 observations. The number of amputations compared to the age related incidence 1979 had increased four times. Age, diabetes mellitus and sex proportions of ischemic amputees were studied and compared to other Scandinavian reports over the last 30 years. The proportion of diabetic amputees (0.37) and the male proportion (0.54) seemed unchanged, but the proportion of amputees at least 80 years old had increased from about 0.09 to 0.38.

Improved wound healing in transtibial amputees receiving supplementary nutrition

Summary. The objective of this prospective study of matched controls was to find out whether supplementary nutrition would improve wound healing and decrease mortality in patients undergoing transtibial amputation for occlusive arterial disease. The nutritional status of 32 consecutive transtibial amputees was assessed and 28 were classified as malnourished. Supplementary nutrition was given reaching an average intake of 2098 kcal/day for a total of 11 days. In 24 patients, at least 5 days of preoperative supplementary nutrition were given, followed by postoperative treatment for a total of 11 days. Four patients who had an immediate operation were given only postoperative treatment, and 4 were excluded. The controls were 32 amputees in another hospital and matching procedures were carried out with corrections for diabetes, sex, age, smoking habits, previous vascular surgery and living conditions before amputation. Healing, including those healed before death in both groups, occurred in 26 of the nutrition group compared to 13 in the control group, which was statistically significant. Nine patients died within 6 months in the nutrition group compared to 14 of the controls (not significant). Malnutrition was present in nearly 90% of transtibial amputees and supplementary nutrition improved healing, but not mortality.Résumé. L’objectif de cette étude prospective a été d’étudier si une augmentation de l’apport nutritionnel peut ameliorer la cicatrisation et réduire la mortalité chez les malades ayant subi une amputation de jambe en raison d’une maladie vasculaire. L’état nutritionnel de trente-deux patients consécutifs ayant subi une amputation de jambe a étéévalué. Vingt-huit ont été considérés comme malnutris. Une nutrition additionnelle leur a été donnée avec un apport moyen de 2098 kcal par jour pendant 11 jours. Chez 24 malades une nutrition additionnelle, de cinq jours au moins en préopératoire, a été suivie par un traitement postopératoire pour atteindre un total de 11 jours. Quatre malades necessitant une amputation en urgence n’ont re*u le traitement que postopératoire et quatre malades ont été exclus. Trente deux amputés de jambe venant d’un hopital universitaire voisin ont été utilisés comme contrôle, après associations des cas tenant compte de l’age, le sexe, du diabète, de la consommation de tabac, des opérations vasculaires précédentes et des conditions de vie antérieure à l’amputation. L’étude de la cicatrisation a montré que 26 amputés étaient cicatrisés dans le groupe ayant bénéficié d’un apport nutritionnel contre 13 dans le groupe de controle, P= 0.001. Neuf patients sont morts dans les premier six mois dans le groupe ayant bénéficié d’un apport nutritionnel contre 14 dans le groupe de controle, (n. s.). Cette étude montre clairement que près de 90% des amputés de jambe étaient malnutris et qu’un apport nutritionnel a amelioré la cicatrisation du moignon sans pour autant augmenter la survie.

AGE, DIABETES AND SMOKING IN LOWER LIMB AMPUTATION FOR ARTERIAL OCCLUSIVE DISEASE

The increased number of amputations for arterial occlusive disease noted in western countries is only partly explained by increasing numbers of the elderly. A prospective analysis of the influence of diabetes and smoking habits was therefore carried out. In 1978-81, 188 lower limb amputees in Lund were examined and classified as non-smokers, ex-smokers, light smokers and heavy smokers. These figures were compared with corresponding figures among age-correlated controls and to a group of hip fracture patients. The material was divided into men and women and into non-diabetics and diabetics. Smokers had much lower mean age at amputation. Out of 188 amputees only 23 were not either a diabetic, a smoker or 80 years or more. The population study indicates a correlation between smoking and amputation for ichaemia. The coincident increase in cigarette consumption in Sweden is illustrated and it is suggested that smoking should be noted as routinely as diabetes at amputations.

Fine Needle Aspiration Biopsy in the Evaluation of Tumor-Like Lesions of Bone

A consecutive series of bone lesions suspected to be tumors and examined by fine needle aspiration biopsy at the University Hospital Cytology Laboratory in Lund, Sweden, is reported. From 1966 to November 1974, 150 cases were examined. In 123, sufficient cellular material was obtained through aspiration by a needle with an outer diameter of 0.8 mm. The method is described. The reliability of cytology is compared with the results of the definite pathology after open biopsy or extirpation of the lesion. In the series of primary benign lesions 28 out of 39 were correctly diagnosed; among primary malignant 27 out of 38 were correct and among metastases 57 out of 73 were correctly diagnosed including those where insufficient cellular material was aspirated. In cases where sufficient material was achieved the reliability of the cytological diagnosis was around 90 per cent. There was one false positive and two false negative reports of malignancy. Fine needle aspiration biopsy with cytology is recommended as a standard step in orthopedic oncological examinations. It has at least the same degree of diagnostic reliability as other diagnostic methods, such as X-ray, for instance; however, it does not replace open biopsy and histology when mutilating surgery is in question.

Ileopectineal bursitis following total hip replacement

Two cases of ileopectineal bursitis following total hip replacement are presented. Inflammation, infection and trauma are discussed as pathogenic factors. The results of fine needle biopsy, radiologic examination including CT and ultrasonography, as well as bacteriological cultures are described. The therapy was surgical in both cases.

Roentgen Stereophotogrammetric Analysis of Motion between the Bone and the Socket in a Transtibial Amputation Prosthesis : A Case Study

&NA; High‐tech development within prosthetics for lower limb amputees can benefit from high‐tech methods to study the socket fit. Roentgen stereophotogrammetry is one such method with high resolution to study stability with point motion and segment motion simultaneously to show how well bonded the socket is to the stump. It has been used to follow results of total joint replacement concerning loosening and wear of components. In this study, one transtibial amputee was examined with tantalum bone markers implanted through skin and also glued into the hard socket. Four different prosthetic suspensions were used, and we simulated four different gait cycle positions and recorded the micromotions between the tibial bone segment and the hard socket three‐dimensionally. The vertical motion varied 10 to 30 mm and the AP motion 0 to 15 mm. For the first time, we could measure rotation of the socket on the stump about a vertical axis. The rotation in the transversal plane was 7.5 outward. Airtight sleeve with expulsion valve gave the best stability.

Operations, total hospital stay and costs of critical leg ischemia. A population-based longitudinal outcome study of 321 patients

In a longitudinal analysis of all 321 patients in a defined population having surgery for critical leg ischemia during 1 year in Malmöhus county (0.53 million inhabitants), Sweden, we investigated all vascular procedures and amputations on both legs, total hospital stay and hospital costs from the first procedure in each patient until death or at follow-up at least 6 years postoperatively. The first (key) operation during the inclusion year was a reconstructive vascular procedure in 96 patients, a restorative vascular procedure in 111 and a major amputation in 114 patients. One third of those with a reconstructive and half of those with a restorative key procedure had an ipsilateral major amputation. The mean number of surgical procedures and length of hospital stay among all patients were 3 (1-19) procedures and 117 (1-1097) days, respectively. Of the total number of days in hospital, less than half were in surgical departments, 10% in other acute-care departments and almost half in rehabilitation clinics and nursing homes. The total hospital and surgical costs among all patients were USD 15.1 million (mean USD 47,000/patient), with no significant differences in relation to the key operation. We conclude that patients who have undergone surgery for critical leg ischemia accumulate very high total long-term hospital costs due to the need for repetitive surgery and long hospital stays. Our findings also show that a longitudinal study, including hospital stay in departments other than surgical, is necessary for a correct cost-and-outcome analysis.

Risk factors for failed healing in amputation for vascular disease A prospective, consecutive study of 177 cases

We examined factors which may lower the mean amputation age and factors which may serve as predictors of success or failure of amputations in the lower extremities for vascular disease in 177 consecutive amputees. Smoking lowered the mean amputation age by 9 years and diabetes by 3 years. Preoperative absence of gangrene in the ischemic limb predicted a higher risk of failure compared to patients with gangrene. Also preoperative hemoglobin > 120 g/L gave a higher risk of failure. Failure to heal was not correlated with age, sex, diabetes, level of amputation, previous vascular surgery, smoking, preoperative blood pressure, serum creatinine, erythrocyte sedimentation rate, blood glucose or temperature.

Occupation after hip replacement for arthrosis.

After hip replacement for primary arthrosis, 69/104 patients younger than 60 years returned to work within 2 years. Long preoperative sick leave increased the risk of both retirement and long postoperative sick leave. The retirement rate was also influenced by occupation, whereas sex, age, or bilateral operations had no influence on postoperative retirement nor on postoperative sick leave.