Sven Friberg

C-reactive protein (CRP) levels after elective orthopedic surgery.

The levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were determined by serial measurements after four types of uncomplicated elective orthopedic surgery. The type of operations chosen for this study were total hip arthroplasty (primary, n = 109; and revisions caused by aseptic loosening, n = 9), unicondylar knee arthroplasty (n = 39), and lumbar microdiskectomy (n = 36). In all patients, CRP levels increased after surgery, reaching peak levels on the third day after hip arthroplasties (primary, 116 +/- 43 mg/l; revisions, 136 +/- 58 mg/l) and on the second day after knee arthroplasties (140 +/- 46 mg/l) and lumbar microdiskectomy (48 +/- 27 mg/l). C-reactive protein levels usually dropped to normal (less than 10 mg/l) within 21 days after surgery. No correlations were found between CRP response and the type of anesthesia, amount of bleeding, transfusion, operation time, administered drugs, age, or gender. Erythrocyte sedimentation rate increased to peak levels about five days after surgery, followed by a slow and irregular decrease. Still, 42 days after uncomplicated operations ESR often remained elevated. In conclusion, the level of CRP must be considered a better diagnostic aid for the early detection of postoperative infections than ESR. It can be assumed that the rapid decline in CRP after uncomplicated orthopedic surgery will be interrupted by a second rise or by a persisting elevated level if infectious complications occur.

Trochanteric fractures : mobility, complications, and mortality in 607 cases treated with the sliding-screw technique

Six hundred seven trochanteric fractures (563 patients) were treated with a sliding-screw technique and followed clinically and roentgenographically for at least one year. Of 351 patients admitted from their homes, 209 (60%) were discharged to their homes after an average of 18 days in the hospital. During the first year another 61 (17%) patients returned home after rehabilitation in a geriatric ward. Of 446 patients walking without support or with one cane before surgery, 360 (80%) had regained the same mobility after one year. The one-year mortality rate was 18%, while the ten-year rate was 74%. Compared with a control cohort, the mortality rate was increased during the first two years after fracture. The increase in mortality was influenced by advanced age, admission from long-term care institutions, male gender, and ambulatory or nonambulatory status before surgery. Forty-five (7.4%) were reoperated, 17 because of technical complications, three because of infection, and three because of nonunion. No further nonunions occurred. The deep infection rate was nine of 339 (2.7%) before and two of 268 (0.8%) after the introduction of antibiotic prophylaxis. Thromboembolic complications decreased from 4.1% to 1.2% after the introduction of dextran 70 as thromboembolic prophylaxis.

Straight Leg Raising Test Versus Radiologic Size, Shape, and Position of Lumbar Disc Hernias

In 30 patients with a computed tomography-verified lumbar disc herniation, the relation between the straight leg raising test and the size, shape, and position of the hernia was evaluated before, 3, and 24 months after inception of nonoperative treatment. Hernia size was expressed as an index relating it to the size of the spinal canal. The limitation of the straight leg raising test was not related to size or position of the hernia. Before treatment, straight leg raising was equally restricted in patients with sharply pointed or blunt hernias, but after 3 months straight leg raising was less limited in patients with sharply pointed hernias, whereas after 24 months straight leg raising was regularly normalized. Size index was lower for sharply pointed hernias at all three computed tomography scans. A decrease in hernia size over time, irrespective of shape, was not correlated to a concomitant improvement in straight leg raising. It must be presumed that additional factors, such as inflammatory reactions affecting the nerve roots, are of importance for the magnitude of straight leg raising.

Size of Lumbar Disc Hernias Measured Using Computed Tomography and Related to Sciatic Symptoms

The change in the relative size of lumbar disc hernias and its relation to sciatic symptoms was investigated in 30 consecutive patients after conservative treatment of CT verified lumbar disc herniations. CT and clinical examination were performed before the start of therapy (CT1), as well as 3 months (CT2) and 24 months (CT3) after institution of treatment. In each patient the size of the lumbar disc herniation in relation to the size of the spinal canal was measured on identical CT slices and expressed as an index. The disc herniation index decreased markedly from CT1 to CT2 (p less than 0.001). Between CT2 and CT3 the reduction of the hernias was less pronounced and not significant for hernias located centrally but still significant for intermediate (p = 0.03) and lateral (p = 0.04) hernias. The degree of sciatic symptoms also decreased markedly between CT1 and CT2 (p = 0.001) while no further improvement occurred from CT2 to CT3. There was a significant positive correlation between the improvement from sciatic pain and the reduction in the size of the individual hernia (CT1-CT2 p = 0.02, CT2-CT3 p less than 0.001). Thus, the disc herniation index provided a method to study the anatomic effect of conservative treatment as well as a method to evaluate sciatic symptoms in relation to anatomic changes.

Describing the size of lumbar disc herniations using computed tomography. A comparison of different size index calculations and their relation to sciatica.

Study Design The study compared different methods to measure the absolute and relative size of lumbar disc herniations on computed tomography scans and their relation to sciatica. Methods Computed tomography (CT) examinations were done before and at 3 and 24 months after nonoperative treatment in 30 patients with lumbar disc hernistions. The size of the herniation was described by different indexes and related to the degress of sciatica. One index was formed by the area of the herniation in relation to the spinal canal (A-index), whereas two indexes were formed by linear measurements of the herniation in relation to the spinal canal in either two (ST-index) or one direction (S-index). Results Each index was correlated significantly to the degree of sciatica. The area of the herniations decreased markedly over time. Conclusions Linear measurements of the hermiation in two perpendicular directions provide a practical and accurate way of describing the size of lumbar disc herniations.

Sonography of popliteal masses

Sonography of the popliteal space was performed in 28 patients with a history of a popliteal mass, verified by physical examination in all but 7 patients. The final diagnosis was established by needle biopsy or surgery. Three main types of lesions were found sonographically. A thin-walled echo-free cyst was present in 16 patients. The diagnosis in all of these cases was Bakers cyst. Two patients had a mixed cystic and solid lesion, which was found to be a Bakers cyst, with a loose body in 1 case and a soft-tissue sarcoma with hematoma in the other. Three patients showed solid lesions subsequently diagnosed as an old rupture of the semimembranosus muscle, lipoma, and soft tissue sarcoma. Sonography was normal in the 7 patients without clinical evidence of a popliteal mass. Sonography of popliteal masses is useful to distinguish benign cysts from other lesions.

Complications at extraction of the ASIF epiphysiodesis screws

A retrospective study was performed of 30 consecutive patients operated on with ASIF epiphysiodesis for slipped capital femoral epiphysis. During extraction, complications were encountered in 13/23 patients. A total of 38 screws were removed. Thirteen screws broke and another three screws were embedded in bone, making extensive chiseling of cortical bone necessary before extraction was possible. Due to the frequent complications at extraction, the ASIF epiphysiodesis screw is not suitable for treatment of the slipped capital femoral epiphysis.

Assessment of horizontal laminar air flow instrument table for additional ultraclean space during surgery

The area in a vertical ultraclean laminar air flow (LAF) theatre is usually too small to accommodate all the equipment needed for major surgery. We investigated the addition of an instrument table supplied with fixed ultraclean LAF and placed alongside the existing main LAF unit, to determine its physical and bacteriological effect on the main unit. In phase 1, with two investigators but without a patient, smoke tests showed no intrusion of air from the table into the main unit and particle counts did not show any adverse effect on the main LAF unit. In phase 2, during patients undergoing two total knee replacements, the LAF table and a table without LAF were placed alongside the main LAF unit. The tables were subjected to the activity of an extra operating room (OR) nurse working from inside the main LAF vigorously simulating handling of instruments. During this activity, the >5μm particle counts were 275/m(3) at the instrument table with LAF and 8550/m(3) at the table without LAF (P<0.0001). Also, without the OR nurse activity, the particle counts, just inside the main unit and adjacent to the LAF table, were significantly reduced (P<0.03-0.003). Sedimentation plates on the LAF table and in the main unit registered 22 and 25cfu/m(2)/h respectively compared with 45cfu/m(2)/h at the instrument table without LAF. In conclusion, the results from the smoke tests, particle counts and bacteriological evaluation showed that the additional instrument table supplied with LAF is efficient and can be safely used as an extension additional to a main OR LAF unit.

Stabilisation and development of the hip after closed reduction of late CDH

We used ultrasound to investigate the anatomy and stability of the hip during the phase of joint stabilisation after closed reduction of unilateral late CDH in 15 infants aged from two to 15 months. Conservative treatment by splintage in abduction led to complete stability in all hips in from three to 13 weeks. Immediately after reduction, interposed soft tissue caused lateralisation of the femoral head, but this progressively disappeared, and the initially smaller femoral head on the dislocated side regained normal size. Ultrasonic evaluation of the hip in late CDH is a valuable and safe tool; it reduces the need for radiographic examination and improves treatment by visualising the actual pathology. The more frequent use of ultrasound can reduce the need for open reduction in the age group that we studied.

The Roentgenological end Results After Caliper Treatment of Coxa Plana with Varying Degrees of Epiphyseal Involvement

The radiological results after caliper treatment of 45 hips with Coxa Plana are presented. The material was grouped and analysed according to the degree of primary involvement of the epiphysis by the necrotic process. It was found that the risk for deformation of the femoral head became significantly higher in the groups with more extensive involvement of the epiphysis. This observation shows that the primary involvement of the epiphysis has a determining influence on the results. It further indicates that if the radiographic results from different materials of Coxa Plana are to be compared consideration must be given to the primary extent of necrosis of the epiphysis.