Ola Wahlström

Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures. A prospective randomized study of 100 hips

100 patients 75 years or older, with displaced femoral neck fractures, were randomly assigned to osteosynthesis with two parallel and percutaneously inserted screws (Olmed) or total hip arthroplasty (Lubinus IP). Mean age was 84 (75-101) years, 74% were women and 45% had mental dysfunction. General complications were commoner in the arthroplasty group but the mortality rates did not differ. In the osteosynthesis group, fracture complications were seen in 27/50 hips. In the arthroplasty group, dislocation was the main complication and occurred in 11/50 cases. At 3 months and after 1 year, the Harris Hip Scores were significantly better in the arthroplasty group. When mental dysfunction was present, the dislocation rate after arthroplasty was 32%, whereas the reoperation rate after osteosynthesis was 5%. The opposite pattern of complications was found in patients with normal mental function, 12% versus 60%. The 2-year mortality rate among those with mental dysfunction was 26/45, compared to 7/55 of those with normal function (p < 0.001). We conclude that total hip arthroplasty should be considered for a displaced femoral neck fracture in old patients with normal mental function and high functional demands.

Fibroblast proliferation due to exposure to a platelet concentrate in vitro is pH dependent

The influence of platelet‐rich plasma lysates on fibroblast proliferation was studied in culture. Cells were exposed to platelet lysates that had been preincubated at different pHs (5.0, 7.1, and 7.6). Proliferation was evaluated with the MTT assay and incorporation of [3H]thymidine into macromolecules, while type I collagen production was assayed by Western blotting. Enzyme‐linked immunosorbent assays were used to determine platelet‐derived growth factor and transforming growth factor‐β concentrations. Platelets preincubated in an acidic environment (pH 5.0) induced the highest degree of fibroblast proliferation, and the concentration of platelet‐derived growth factor in the different treated lysates was the highest at that particular pH. The concentration of transforming growth factor‐β, however, was lower after incubation at pH 5.0 than at either pH 7.1 or 7.6. These findings may be relevant to normal wound healing in vivo and useful in the treatment of wounds and delayed healing processes. (WOUND REP REG 2002;10:336–340)

Monitoring referral and treatment in soft tissue sarcoma: Study based on 1,851 patients from the Scandinavian Sarcoma Group Register

This report is based on 1.851 adult patients with soft tissue sarcoma (STS) of the extremities or trunk wall diagnosed between 1986 and 1997 and reported from all tertiary referral centers in Norway and Sweden. The median age at diagnosis was 65 years and the male-to-female ratio was 1.1:1. One third of the tumors were subcutaneous, one third deep, intramuscular and one third deep, extramuscular.The median size was 7 (1-35) cm and 75% were high grade (III-IV). Metastases at presentation were diagnosed in 8% of the patients. Two thirds of STS patients were referred before surgery and the referral practices have improved during the study. The preoperative morphologic diagnosis was made with fine-needle aspiration cytology in 81%, core-needle biopsy in 9% and incisional biopsy in 10%. The frequency of amputations has decreased from 15% in 1986-88 to 9% in 1995-1997. A wide surgical margin was achieved in 77% of subcutaneous and 60% of deep-seated lesions. Overall, 24% of operated STS patients had adjuvant radiotherapy. The use of such therapy at sarcoma centers increased from 20% 1986-88 to 30% in 1995-97. Followup has been reported in 96% of the patients. The cumulative local recurrence rate was 0.20 at 5 years and 0.24 at 10 years. The 5-year metastasis-free survival rate was 0.70.

MULTIPROFESSIONAL EDUCATION IN THE MEDICAL CURRICULUM

The aim of this project was to design a programme for the students at the Faculty of Health Sciences (FHS) which has long fostered multiprofessional education, and encourages development of positive attitudes and skills related to collaboration with other health professionals. This should be characterized by mutual respect and understanding and should also provide students with insight into the various professional roles and competencies involved in collaboration within the health care system. A multi‐professional training ward, and since January 1996 a student‐manned training ward, has been in operation at the Department of Orthopaedics, University Hospital, Linköping. The care, treatment and rehabilitation of patients is performed by students from all the education programmes at the FHS. While the supervisers are medically responsible, they generally only observe and provide guidance without taking too much active part in the practical work. The students are recruited during one of their last two semesters when they have attained fairly good insight into their future professional roles. Experience thus far has shown that a training ward seems to be a very efficient way of improving the ability to work as a team with real patients, and is an inspiring and efficient means for obtaining these skills which, in turn, are essential in future professional work. This paper reports the implementation and first experiences of the training ward. A detailed evaluation of the effects of an educational ward, taking into account the opinions and attitudes of students, teachers and patients, is in progress.

Revision of infected hip replacement: Two-stage procedure with a temporary gentamicin spacer

We revised 5 infected totally-replaced hips in 2 stages. At the first operation a gentamicin-loaded modelled cement spacer was inserted, and the definitive prosthesis was inserted 3-8 weeks later. 9-24 months after the last operation, there was a recurrent infection in 1 case. 2 of the patients could walk in the interval.

Inflammatory response in 85 patients with loosened hip prostheses: A prospective study comparing inflammatory markers in patients with aseptic and septic prosthetic loosening

Background The most common complications of prosthetic hip joints are aseptic mechanical failure and infection. Delayed low-grade infections are seen most often, and they are also most difficult to distinguish from aseptic mechanical failures. Methods We conducted a prospective study to compare inflammatory markers in patients diagnosed with aseptic or septic prosthetic loosening. The diagnostic criteria were based on the decisions of experienced orthopedic surgeons and microbiological analysis of periprosthetic tissue samples taken perioperatively. Results Coagulase-negative staphylococci were the commonest pathogens in the infected patients. Pre- or perioperative elevation of C-reactive protein and erythrocyte sedimentation rate were significantly greater in the infection group, as were white blood cell count and levels of cytokines in synovial fluid. The patterns of infiltration of inflammatory cells in periprosthetic tissue were also significantly different between the groups. Interpretation A combination of clinical judgment and multiple tissue samples constitutes a good platform for distinguishing between septic and aseptic loosening of prostheses. Moreover, the combined use of several laboratory and histopathological markers of inflammation, especially infiltration of polymorphonuclear cells, further helps the diagnosis.

Heterotopic bone formation prevented by diclofenac: Prospective study of 100 hip arthroplasties

A double-blind, placebo-controlled study was done on the influence of diclofenac, a nonsteroidal anti-inflammatory drug, on heterotopic bone formation after total hip arthroplasty. Totally, 100 operations were involved, and a follow-up was performed after 1 year. There were no cases of substantial bone formation in the treated group versus two thirds of the cases in the placebo group, and some of these had pain. Because side effects of treatment with diclofenac are few and mild, we advocate prophylactic use of this drug.

A comparative study between McKee-Farrar and charnley arthroplasty with long-term follow-up periods

One hundred seventy-seven consecutive total hip arthroplasties on 169 patients, 107 with a McKee-Farrar prosthesis and 70 with a Charnley low-friction arthroplasty, were followed in a prospective study. Fifty-five patients (31%) representing 55 hips died during the study period. Four (2%), two McKee-Farrar and two Charnley, were lost to follow-up study. The remaining 55 McKee-Farrar and 41 Charnley hips were evaluated after a mean follow-up period of 11.5 years (range, 10.1-13.5 years). Twenty-two (12%) of the hips had been revised. A survival study was performed and the two techniques were compared with regard to walking ability, Harris hip score, and radiologic assessment. No major differences were observed. The mean annual revision rate in this series was 1.3%. Walking distance increased from 200 m before operation to 2,000 m 1 year after operation and then remained constant during the observation time. The results, using the Harris hip score, were good or excellent (greater than 80 points) in 47%. Thirty hips (32%) showed signs of prosthetic loosening; 17 of these caused pain on weightbearing occasionally or regularly and 13 caused no pain at all.

Liposarcoma : Outcome Based on the Scandinavian Sarcoma Group Register

The aim was to study the clinicopathological characteristics, treatment, and outcome of liposarcoma in an unselected, population‐based patient sample, and to establish whether treatment was according to the Scandinavian Sarcoma Group (SSG) treatment guidelines.BACKGROUND The aim was to study the clinicopathological characteristics, treatment, and outcome of liposarcoma in an unselected, population-based patient sample, and to establish whether treatment was according to the Scandinavian Sarcoma Group (SSG) treatment guidelines. METHODS The SSG Pathology Board reviewed 319 liposarcoma cases reported between 1986 and 1998. After the review, 237 patients without metastasis were analyzed for local recurrence rate in relation to surgical margins, radiotherapy, occurrence of metastasis, and survival. RESULTS Seventy-eight percent of the patients were primarily operated on at a sarcoma center, 45% with wide margins. All patients operated on outside the center had nonwide margins. Low-grade lesions constituted 67% of cases. Despite nonwide surgery, only 58% of high-grade lesions were treated with postoperative radiotherapy. The risk of local recurrence after nonwide surgery, without irradiation, was 47% for high-grade lesions. The estimated 10-year, local recurrence-free and metastasis-free survival in the low-grade group was 87% and 95%, respectively. In the high-grade group, it was 75% and 61%, respectively. Independent adverse prognostic factors for local recurrence were surgery outside a sarcoma center and histological type dedifferentiated liposarcoma. For metastases, they were old age, large tumor size, high grade, and histological type myxoid liposarcoma with a round cell component. Radiotherapy showed significant effect on local recurrence rate for the same grade and margin. CONCLUSIONS Patients with liposarcoma should be treated at specialized centers. Postoperative radiotherapy decreases the local recurrence rate. To maintain quality and provide support for further trials, reporting to quality registers is crucial.

Consequences of local recurrence of soft tissue sarcoma : 205 patients from the Scandinavian Sarcoma Group Register

From the Scandinavian Sarcoma Group Register, information on 1,224 surgically-treated patients with soft tissue sarcoma (STS) of the extremity or trunk wall, diagnosed between 1987 and 1995, was collected. 205 patients, one third of whom were referred to a center with a local recurrence, had a total of 284 local recurrences. This analysis describes the treatment for these local recurrences, complications and risk of further recurrences. 169 patients were surgically treated for their first local recurrence. An intralesional or marginal margin was achieved in 110 of these patients, 59 of whom were also given radiotherapy. 54 of the 169 patients had a second local recurrence. The second local recurrence rate was 0.50 if the first local recurrence had been treated with only surgery with a marginal margin, compared to 0.28 if treated with surgery with a marginal margin and radiotherapy or with a wide margin (p = 0.0008). In extremity STS, the crude amputation rate for local recurrences was 0.22 (31 of 142)--i.e., higher than for primary tumors 0.09 (96 of 1065) (p < 0.0001). A high local recurrence rate after treatment outside of sarcoma centers has earlier been shown. We conclude that the consequences of local recurrence in terms of morbidity and costs justifies referral of STS patients for multidisciplinary evaluation and multimodality treatment.