Lars Irstam

Long-term anatomic and functional changes in patients with adolescent idiopathic scoliosis treated by Harrington rod fusion.

One hundred patients from the Gothenburg Scoliosis Data Base were studied. They met the following criteria: (1) adolescent idiopathic scoliosis (2) completion of treatment before age 20, (3) a minimum follow-up of five years thereafter, (4) a minimum age of 22 years at final follow-up, and (5) operation performed by the senior author. Of these, 95 were personally examined. The surgical technique from 1968 to 1973 included a two-stage Harrington distraction, with fusion added at the second operation (52 patients). From 1973 to 1975, 48 patients were treated with a one-stage distraction and fusion after a week of preoperative Cotrel traction. Postoperatively, all patients were treated with a Milwaukee brace. A spinal examination and functional assessment, including a questionnaire and pain drawing, full standing anterior–posterior (AP), and lateral roentgenograms of the spine, was performed by independent observers. Eighty-five subjects without scoliosis served as a control group. The radiographic evaluation showed the usual nearly 50% permanent correction at the follow-up examination averaging nine years postoperatively. Lateral roentgenograms, however, demonstrated in 52% flattened or kyphotic cervical spines producing no significant complaints, non-significant flattening of the thoracic kyphosis, but significant lowering of the lumbar lordosis. Fifteen of the 24 patients with distal hook insertion and fusion including L4 or L5 demonstrated retrolisthesis. All had significant low-back pain. Degenerative facet joint changes and disc space narrowing was noted in 11 patients, again with a distal hook purchase in L4 or L5. Compared to the controls, the operated patients, as a group, revealed no lessened activity or back pain at any location. The operated patients, the majority (76%) cosmetically pleased, functioned at the same level as age-matched controls in regard to marriage, child-bearing, sports activities, and job performance. Although, as a group, the operated patients were functionally and socially very well indeed, low-back pain was found statistically significantly more often in patients in whom fusion was carried down to L4 or L5, compared to the control subjects.

Intrinsic disc pressure as a measure of integrity of the lumbar spine

Intradiscal pressure and volume measurements were made In 84 fresh cadaveric lumbar spine disc spaces. The nucleus was injected with a roentgenographic contrast agent under fluoroscopic examination. The intrinsic pressure, the pressure at which the agent entered the disc, and the maximum pressure that the disc could hold were measured. The discs were graded for degeneration. The intrinsic and maximum pressures were found to be inversely related to disc degeneration grade, and directly related to each other. Relatively greater degeneration was found at lower levels of the lumbar spine as compared to the upper levels. The intrinsic disc pressure may prove to be a useful clinical tool in the evaluation of spinal integrity.

Elongation in Profundus Tendon Repair: A Clinical and Radiological Study

A radiographical study of 63 digits with tendon lacerations within the digital sheath is presented. 60 of these digits were evaluated clinically 6-36 months (mean 15 months) after surgery. At primary tendon repair one wire marker was placed on each side of the repair site in the profundus tendon. The distance between the markers was measured at operation and postoperatively on 3 different occasions on radiograms. The results showed that increase of the distance between the markers by more than 5 mm, considered to indicate elongation in the suture, occurred in 25 out of 59 repaired profundus tendons (42%) and in most instances this happened during the period of immobilization. The cause of elongation could be identified in 9 digits. In 5 it was due to rupture of the suture material, the tendons being repaired with 5-0 Flexon steel wire. In the other 4 digits, sutured with 4-0 Silky Polydec, slipping of the knot was revealed at reoperation. There was a strong correlation between increased distance between the markers and a poor outcome, elongation being the most frequent cause.

FEMORAL NECK FRACTURES IN YOUNG ADULTS

A total of 110 fractures of the neck of femur were studied in 108 patients 17 to 50 years old. The aims were to analyze why these fractures occur in young adults, and what results can be expected after internal fixation. Severe trauma caused about half of the fractures. In the remaining group chronic and disabling disorders were usually present at the time of injury. Seventeen patients were known to abuse alcohol. Aseptic necrosis with late segmental collapse occurred in 41 per cent of the hips (45/110), comparatively more often in patients who were 45 years or younger. Only 16 of the 73 patients who were seen at follow-up (22 per cent) had a perfect result. It is concluded that femoral neck fractures in patients younger than 45 years occur because of significant trauma in a healthy subject, or minor trauma in subject with predisposing disease. The incidence of late segmental collapse is greater than in elderly patients with femoral neck fractures. A less satisfactory result can therefore be expected.

Roentgenographic Measurement of Lumbar Intervertebral Disc Height

The influences of differences in both intervertebral motion segment orientations and in reader judgments on measurements of the apparent intervertebral disc heights in lateral roentgenographs of the lumbar spine were examined. Forty-nine roentgenographs were obtained of nine discs that were tilted laterally up to ± 10 degrees, and rotated longitudinally up to ± 20 degrees. Three orthopaedic surgeons and three radiologists measured disc heights from five of these roentgenographs, all using the same measurement method. The differences in apparent height that resulted from the orientation changes and differences in judgments among the six readers were considerable, usually of the order of one half of the nominal disc height. The results show that, while roentgenographic measurements can be used to estimate disc height, accurate measurements cannot readily be made from routine roentgenographs, and the interpretation should always be cautious.

Fracture of the neck of the talus. A clinical study.

A clinical evaluation of 46 patients treated for fractures of the neck of the talus has been made after a mean follow-up period of 6 years. The cause of injury was most frequently motor vehicle accidents (26) and falls from heights (11). In non-displaced fractures plaster with immobilization was used and displaced fractures were treated by closed or open reduction. At follow-up most of the patients complained of symptoms hampering daily activities. Objectively, excellent to good results were obtained in 75 per cent of the non-displaced fractures and in 42 per cent of the displaced. Delayed union occurred in 15 per cent. Avascular necrosis was found in 15 per cent and degenerative changes in 97 per cent. A decreased density of bone under the articular cartilage, called subchondral atrophy, was seen in 50 per cent.

The Crush-cleavage Fracture: A “new” Thoracolumbar Unstable Fracture

Among 14 patients with unstable thoracolumbar fractures examined by both conventional radiography and CT, we found seven patients with a “new” common fracture pattern. This fracture pattern consisted of (1) superior disc injury, (2) crush fracture of the upper half of the vertebral body, (3) sagittal fracture (cleavage fracture) of the lower half of the vertebral body, (4) bone fragments in the spinal canal, and (5) laminar fracture. Five of the seven patients had sustained their injuries in vertical falls; all five had primary neurological deficit symptoms. We consider this fracture to be unstable.

Unstable Thoracolumbar Fractures: A Study by CT and Conventional Roentgenology of the Reduction Effect of Harrington Instrumentation

Fourteen patients with unstable thoracolumbar fractures were examined with conventional roentgenologic technique and CT before and after operation with Harrington instrumentation. CT was superior in evaluating posterior elements, bone fragments in the spinal canal, and degree of narrowing of the spinal canal. Harrington rods restored the general spinal alignment. However, even after surgery, the midsagittal diameter, as well as the cross-sectional area of the spinal canal were still diminished by 26%. The reduction of the spinal canal improved significantly by early surgical intervention. Open reduction and stabilization with Harrington rods and fusion within three days after injury is recommended.

Metacarpophalangeal Joint Replacement with Osseointegrated Endoprostheses

A new type of endoprosthesis for reconstruction of the metacarpophalangeal (MCP) joint has been tested. The novel arthroplasty consists of a joint mechanism with two screw-shaped fixtures for bone anchorage. These fixtures, of commercially pure titanium, are gently screwed into the anchoring bone on each side of the diseased joint, the aim being to achieve osseointegration, i.e. a direct contact between implant and bone without interposed soft tissue layers. The hand was immobilized in a dorsal splint for 8-10 days post-operatively after which a carefully controlled mobilization program was initiated. In principle, the titanium fixtures, the surgical technique and the primary immobilization represent an approach similar to that previously used in various reconstruction procedures of the jaw. This paper describes 5 case histories of reconstructions required because of osteoarthrosis in a single MCP joint. Prior to the operation, all patients suffered from severe problems resulting from their arthrotic joints and they had not been able to work for several months. After surgery they were evaluated by a clinical assessment program and X-rays were taken at various times of follow-up. As well as visual inspection all radiograms were subjected to densitometry by means of a computer-based image-analysis system in order to provide information on the development of bone density in the bone-to implant interface region. From a functional point of view the treatment with osseointegrated prostheses must be regarded as being successful. All patients were able to go back to their original work and their hands had a satisfactory range of movement and grip strength with no signs of impaired function on longer follow-up time. Clinical problems were one re-operation, one case of implant fracture and one case requiring exchange of the joint mechanism. The computer-assisted evaluation of the radiograms revealed the presence of calcified tissue in many sections where the naked eye was not capable of differentiating any bone. In conclusion, it seems possible to establish osseointegration of MCP-endoprostheses in the arthrotic human joint in complicated cases which were regarded as contraindicated for any other joint arthroplasty.

Metatarsal head resection in the treatment of the rheumatoid forefoot.

When conservative treatment in the management of the painful rheumatoid forefoot fails, surgery should be advocated. The aim is to relieve the sole from pressure on the metatarsal heads, which causes callosities on and pain in the forefoot. Various surgical procedures have been described, but they have in common to replace or remove the fat pad under the metatarsal phalangeal joints, to resect the metatarsal heads and, in doing this, restore the metatarsal ends to a flat arc. For if the intermediate metatarsals are left too long, new pressure points may develop, with ensuing pain. In this investigation a 4 1/2-year follow-up is presented of 32 patients operated on with metatarsal head resection in 59 feet. Twenty-two patients representing 39 feet were very satisfied, whereas 8 patients representing 15 feet were dissatisfied. Walking ability improved considerably; standing on toes improved; muscle power of toes improved. Despite attempting to maintain the metatarsal arc as a flat curve, this proved to be uneven in 25 feet, but did not jeopardize the results. The complications were minor and did not influence the final results. These, however, were decidedly influenced by the functional class of the patient at the time for investigation. Surgical management of the painful rheumatoid forefoot appears to be a recommendable procedure.