Carl C. Arnoldi

INTRAOSSEOUS HYPERTENSION AND PAIN IN THE KNEE

The intraosseous pressure in the femur and tibia near the knee and in the internal saphenous vein at knee level was measured in fifty-three patients with suspected knee lesions. There were four groups: with and without degenerative osteoarthritis and with and without aching rest pain of the knee region. Low intraosseous pressures were found in patients with neither osteoarthritis nor rest pain, and in half the patients with osteoarthritis but without rest pain. Low pressures were found in the tibia, but very high intraosseous pressures were found in the femur in most patients with osteoarthritis and rest pain. Patients with no osteoarthritis but with rest pain mostly had high pressures in both the tibia and the femur.

IMMEDIATE EFFECT OF OSTEOTOMY ON THE INTRAMEDULLARY PRESSURE OF THE FEMORAL HEAD AND NECK IN PATIENTS WITH DEGENERATIVE OSTEOARTHRITIS

Recently, Arnoldi, Linderholm & Miissbichler (1971, and to be published) demonstrated a considerable hypertension in the cancellous bone marrow of the proximal part of the femur in patients with advanced stages of coxarthrosis. Simultaneous examinations by means of intraosseous phlebography indicated that the high pressure was accompanied by impaired venous drainage from the femoral head and neck. There are indications that intramedullary hypertension may be a causative factor for the aching rest pains typical of these patients. Therefore we have thought it of interest to investigate the effect upon intramedullary pressure of two operative procedures routinely performed for painful conditions in osteoarthritis of the hip. In both procedures the medullary space is opened and drained, in osteotomy, in the subtrochanteric region, in Smith Petersen cup arthroplasty by removal of bone and cartilage from the femoral head. In the present study the immediate effect of both procedures upon the intramedullary pressure was tested. MATERIAL Two groups of patients with degenerative osteoarthritis of the hip joint were examined. The first group consisted of seven patients treated by means of intcrtrochanteric osteotomy. In the second group, containing eight patients, Smith Petersen cup This work was supported by the Swedish Medical Research Council (Project No.

Intraosseous Phlebography, Intraosseous Pressure Measurements and 99mTc-Polyphosphate Scintigraphy in Patients with Various Painful Conditions in the hip and Knee

Twenty-five patients with pain in the knee or hip were examined by means of bilateral intraosseous phlebography, intraosseous pressure measurements and 99mTechnetium polyphosphate scintigraphy. All patients with typical rest pain--either due to osteoarthritis or to the intraosseous engorgement-pain syndrome--showed venous stasis and increased pressure in the bone marrow near the painful joint and abnormally high uptake of the radiotracer. In patients with other types of pain this correlation was absent. The results indicate that 99mTechnetium polyphosphate scintigraphy can be used as a screening method in the diagnosis of the intraosseous engorgement-pain syndrome in patients with a typical history. However, increased isotope uptake in a joint region may be due to a variety of other causes. The identical findings with all three methods of investigation in patients with the intraosseous engorgement-pain syndrome and osteoarthritis suggest a common pathomechanism.

Fracture of the femoral neck. II. Relative importance of primary vascular damage and surgical procedure for the development of necrosis of the femoral head.

The opinion is widely held that interruption of the arterial flow through the retinacular arteries to the femoral head is the main cause of avascular necrosis after fracture of the neck. In this study the state of the vascular supply to the femoral head was assessed--prior to osteosynthesis--by means of intramedullary pressure measurements in the femoral head and neck in 72 patients with medial neck fractures. The patients were followed 2 or 3 years or until avascular necrosis became evident. The relative importance of primary avascularity and surgical technique for the development of necrosis suggests that damage to the retinacular arteries may not be the single decisive factor in the pathogenesis of femoral head necrosis. Proper fracture reduction with extensive contact between the cancellous bone surfaces and stable fixation seemed to be more important, probably because they offer the best possibilities for re-establishment of transosseous blood flow across the fracture site.

The synovial membrane in human coxathrosis: light and electron microscopic studies.

Changes of the synovium are in integral part of osteoarthritis. Most authors regard these changes as secondary to cartilage degeneration. However, synovitis is a very early feature in osteoarthritis, and increased knowledge of changes in the chemical composition of the synovia focused our attention on the histologic characteristics of osteoarthritic synovium. Light and electron microscopic studies of the synovial membrane from patients with osteoarthritis and rheumatoid arthritis of the hip joints were performed. Two distinct types of osteoarthritic synovitis were observed: an early proliferative from characterized by venous stasis with edema, free erythrocytes and hemosiderine deposits in the interstitial tissue, that suggested increased capillary permeability. In the late form, fibrous synovitis, the microscopic picture was dominated by dense fibrous tissue. Synovium from rheumatoid arthritis showed the same vascular changes as in osteoarthritis. In addition, the histologic picture was characterized by severe inflammatory changes. In osteoarthritis the signs of inflammation were moderate or absent. The development from proliferative into fibrous synovitis is probably the result of long-standing chronic venous insufficiency. The essential feature of osteoarthritic proliferative synovitis--venous stasis with increased capillary permeability--correlates well with most of the known changes in the composition of the synovial fluid.In patients operated on for painful coxarthrosis, the synovium of the hip joint is always visibly abnormal. Most authors seem to agree with Lloyd-RobertsI2 that the changes in the synovium are secondary to cartilage destruction and result from displacement of joint detritus into the synovium. The changes in osteoarthritic synovium have been judged histologically to be nonspecific. I n Clinical experience suggests, however, that synovitis is a very early feature of osteoarthritis and that the synovial fluid-a dialysate of blood plasma from the synovial capillaries to which hyaluronate, synthesized by synovial lining cells, is added-is the vehicle that supplies oxygen and nutrition to the cartilage. Recent findings, such as a low oxygen tension in osteoarthritic synovia,I4 changes in the protein pattern that suggest an increased perme-

Experimental Osteoarthritis in the Rabbit: A Study of 133Xenon Washout Rates from the Synovial Cavity

Synovial perfusion in 6 rabbit knees, with experimentally induced osteoarthritis (joint instability), was studied by recording the initial 133Xe washout rates from the joint space. The unstable osteoarthritic knee was compared with the contralateral sham operated control knee at intervals of 6 to 96 weeks postoperatively. Within the first half year the ratio between the 133Xe washout rates in the osteoarthritic and control joints was significantly increased. These findings were supported by the increased blood flow to the joint region, visualized by scintigraphy of osteoarthritic rabbits given 99mTc-microspheres intracardially. However, methodological sources of error do not allow any conclusions regarding the much less increased 133Xe washout rates found in advanced osteoarthritis. The initially increased synovial blood flow coincided with the existence of joint effusion and the early development of osteophytes, all conditions supposed to be a consequence of posttraumatic synovitis. Attention is drawn to these pathogenic phenomena in studies dealing with the initial changes in experimental models of osteoarthritis and to a possible etiological significance.

On the Conditions for the Venous Return From the Lower Leg in Healthy Subjects and in Patients With Chronic Venous Insufficiency

From The Orthopedic Clinic, Head: L. Hult, Professor of Orthopedics; the Department of Clinical Physiology, Head: H. Linderholm, Professor of Clinical Physiology and the Department of Diagnostic Roentgenology, Former Head: T. Greitz, Professor of Diagnostic Roentgenology, University of Umeå, Sweden. The return of the venous blood from the lower extremity towards the heart in the upright position takes place against the forces of gravity. It has long been recognized that muscular exercise with compression of the adj acent veins increases the proximal flow of blood, and the idea of a &dquo;musculovenous pump&dquo;

Intraosseous Pressures in Patients With Different Types of Fracture of the Femoral Neck

monly believed to be important for the outcome of treatment, but the opinions as to the relative importance of these factors differ widely. As intraosseous pressure measurements may give information regarding the state of the arterial supply to and the venous drainage from the femoral head, we considered it of interest to examine the pressure tracings from the collum and caput femoris as indicators of traumatic vascular disturbances and their frequency in different types of fracture of the femoral neck.

Resurfacing of Depression Fractures of the Lateral Tibial Condyle: A Report of Five Cases

Five patients with fractures of the lateral tibial condyle were treated operatively by resurfacing of the lateral tibial plateau by means of a Marmor polyethylene tibial prosthesis. The indications were persistent pain and valgus deformity. In four patients, in whom the cartilage of the lateral femoral condyle was normal at the time of operation, the results were excellent. One patient with osteoarthritic cartilage degeneration of the femoral condyle was not improved by the operation.