Göran Sjödén

Poor reproducibility of classification of proximal humeral fractures Additional CT of minor value

Fractures of the proximal humerus can be described using the Neer and AO fracture classifications. To assess the reproducibility and reliability of these classifications, we investigated 26 proximal humeral fractures with both plain radiographs and CT. 5 specialists in orthopedic surgery and 5 specialists in radiology independently classified all radiographs on 2 occasions. There was a moderate agreement between the observers when using the Neer classification, but only a fair agreement with the AO classification. The Neer system had a kappa value of 0.42 and the AO had a value of 0.31 in the first assessment. In the second assessment the kappa values were 0.45 and 0.30, respectively. Intraobserver reproducibility was slight to almost perfect agreement with Neer (kappa range 0.20-0.85) and slight to moderate agreement with AO (kappa range 0.16-0.60). The observers most familiar with shoulder fracture radiographs and shoulder fracture treatment were more consistent in their classifications. We conclude that even with CT, the fracture classifications of Neer and AO have a low consistency. Neither classification system is reproducible enough to allow comparisons of different studies.

1α-Hydroxyvitamin D2 is Less Toxic than 1α-Hydroxyvitamin D3 in the Rat

Abstract An LD50 of 0.2 mg/kg body wt has been determined for 1α-hydroxyvitamin D3in the rat. In comparison, the LD50 for 1α-hydroxyvitamin D2 is between 3.5 and 6.5 mg/kg. In terms of chronic toxicity, lα-hydroxyvitamin D3 at a dose of 5 μg/kg/day causes death of one-half the animals in a 4-week period. On the other hand, 20 μg/kg/day of 1α-hydroxyvitamin D2 is required to induce similar toxicity. The body weight record and renal calcium accumulation during chronic treatment support the above conclusion. It therefore appears that 1α-hydroxyvitamin D2 is between 5 and 15 times less toxic than 1α-hydroxyvitamin D3. This surprising result prompted a reexamination of the relative biological activity of 1α-hydroxyvitamin D2and 1α-hydroxyvitamin D3, Both compounds are equally potent in the stimulation of intestinal calcium transport, bone calcium mobilization, in the elevation of serum phosphorus, and in the healing of rickets in the rat. The reason for lower toxicity of 1α-hydroxyvitamin D2 is unknown. The results suggest that 1α-hydroxyvitamin D2might represent a therapeutically Superior compound.

3D-radiographic analysis does not improve the Neer and AO classifications of proximal humeral fractures.

The Neer and AO fracture classifications for fractures of the proximal humerus have shown poor reproducibility based on plain radiography. We wanted to investigate whether the addition of 3-dimensional (3D) reconstructions would increase the reproducibility of classification. 7 observers independently classified 24 fractures of the proximal humerus using both plain radiographs, CT and 3D and the classification was repeated 2 months later. There was a moderate interobserver agreement when using the Neer classification, but only a fair agreement with the AO classification. The Neer system had a mean kappa value of 0.44 and the AO had a value of 0.32 for the first assessment. In the second assessment, the mean kappa values were 0.49 and 0.34, respectively. Intraobserver reproducibility was fair to substantial agreement for Neer (kappa range 0.27-0.73) and for AO (kappa range 0.29-0.74). In conclusion, the addition of CT and 3D to plain radiographs did not improve the reproducibility of the classifications of Neer and AO of the proximal humerus.

Late results of the Souter-Strathclyde total elbow prosthesis in rheumatoid arthritis 6/19 implants loose after 5 years

We performed total elbow replacement, using the Souter-Strathclyde prosthesis in 19 elbows of 18 patients with rheumatoid arthritis and followed the patients for 5 (1-11) years. Pain relief was achieved initially in all patients. The average range of flexion-extension was increased by 12 degrees and pronation-supination by 40 degrees. There were no infections. 1 patient sustained an intraoperative fracture of the medial epicondyle, 3 patients developed neuropathies and 1 patient had an immediate postoperative dislocation of the joint. At follow-up, 6 prostheses had radiographic loosening, with sagittal titling and migration of 4 humeral components. 2 patients had clinical symptoms of loosening.

The Souter-Strathclyde elbow replacement in rheumatoid arthritis 13 patients followed for 5 (1-9) years

13 Souter-Strathclyde unconstrained elbow prostheses for rheumatoid arthritis were followed for 5 (1-9) years. Pain relief was achieved in all the patients. Flexion-extension was increased by 22 degrees, and pronation/supination by 27 degrees. There were no infections. Three humeral components were radiographically loose, but no patient had any symptoms. One patient sustained a fracture of the distal humeral epicondyle, two patients developed neuropathies and one patient had a postoperative dislocation that needed treatment with an external Hoffman fixator.

Verapamil induces increased bone volume and osteopenia in female rats but has the opposite effect in male rats

SummaryVerapamil inhibits the intestinal absorption of calcium (Ca) and increases serum parathyroid hormone in rats. The effects of verapamil on bone tissue after long-term treatment is, however, not well described. Adult female and male Sprague-Dawley rats received verapamil in their drinking water at a dosage of 0.075 mg/ml (low dose) or 0.75 mg/ml (high dose) for 12 weeks; control rats received only drinking water. All rats were fed a diet containing 0.1% Ca and 0.5% P. In female rats, the amount of bone ash per volume was significantly reduced from 0.742 g/ml in controls to 0.713 g/ml after low-dose treatment of verapamil, and to 0.667 g/ml following high-dose treatment (P<0.01). The tibial length was increased from 39.7 mm in controls to 40.3 mm or to 40.7 mm after low or high doses (P<0.01). The tibial volume increased from 0.385 ml in controls to 0.397 ml after low doses and to 0.429 ml after high doses (P<0.01). In contrast, in male rats the amount of bone ash per volume was significantly increased from 0.578 g/ml in controls to 0.580 g/ml after low doses and to 0.620 g/ml after high doses of verapamil (P<0.01). The tibial bone volume in males as decreased from 0.633 ml in controls to 0.641 ml after low doses and to 0.583 ml after high doses (P<0.05). The tibial length in the males was not changed by verapamil. The intestinal absorption of Ca was reduced in male rats from 5.28 in controls to 4.03 (serosa/mucosa) after low-dose treatment and to 2.46 after high-dose treatment with verapamil (P<0.05). In female rats, the intestinal absorption of Ca did not change after verapamil treatment. Thus, chronic treatment with verapamil in female rats induced osteopenia whereas in male rats bone growth was inhibited.

Ovarian carcinoma metastasis to the little finger

Endometrioid carcinoma is the second most common carcinoma of the ovaries. We report the first case of a poorly differentiated endometrioid ovarian carcinoma that metastasized to bone.

The effect of prednisolone on kidney calcification in vitamin D-treated rats

SummaryGlucocorticoids are often used to treat hypercalcemia due to vitamin D overdosage. We measured the effect of 1.5 mg/day of prednisolone on the amount of calcium deposited in the kidney of rats dosed with either 500 ng/d or 2000 ng/day of 1-alphaOHD2 or 1-alpha OHD3. The rats were given a diet containing 0.3% calcium and 0.5% phosphate. A second group of rats received 2000 ng/d of the vitamin D analogs and a diet which contained only 0.02% calcium. After 6 weeks, rats given the vitamin D analogs had two to six times more calcium in the kidney compared with the controls (0.096–0.276 mg vs. 0.240–1.064 mg). When a pharmacological dose of prednisolone was added to treatment, calcium in renal tissue increased to 0.305–3.083 mg. The urinary output of calcium seemed to be increased by prednisolone whereas the serum calcium was lowered. It appears that glucocorticoids given at the same time as vitamin D compounds increases the risk for nephrocalcinosis possibly due to increased amounts of calcium in the urine.