[The problem of stumps in flexion contracture (author's transl)].
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Successful outcomes in hallux limitus surgery are still difficult to reproduce consistently. An attempt is made to improve these results by presenting a systematic approach to surgical reduction of this deformity by isolating several important steps. Emphasis is placed equally on both the soft-tissue and osseous structures. Cartilage grafting and replacement techniques may soon provide more options in joint salvage.
Juvenile chronic arthritis is resulting in joint destruction and frequently also in growth disturbances. In less than 50% pain is the cause of functional disability. It is important for rheumasurgeons to differentiate between the three main types of JCA because of the different prognosis. It is also necessary to realize the involvement of all connective tissue and the multiple organ affections in this disease, especially the kidney-function and the hematopoietic system. The natural course of the disease is characterized by fluctuations between remissions and exacerbations, more irregularly than in the adult type of Rh.A. The good results of rheumasurgery are highly dependent on an interdisciplinary combined unit, preferably working "on the same floor" in daily cooperation. Special training in rheumasurgical operative technique is necessary. Prophylactic measures against joint contractures is of great importance and should be common knowledge of all members of the therapeutic team. During a period of 13 years 528 synovectomies were performed. In a controlled study of open knee-synovectomies, recurrence of the inflammation was rarely seen when a radical early synovectomy had been performed. The centralized unit with well experienced staff, who master the problems of anesthesia, medication, intraoperative blood-transfusion and physiotherapy pre- and post-operatively, may obtain good results in the management of this difficult disease.
Patients undergoing arthroplastic surgery of the lower limbs and those with multiple injuries have a high risk of thromboembolism. Enoxaparin is a highly effective antithrombotic drug that is well tolerated and without the need for monitoring. Numerous controlled trials in these patient groups have demonstrated enoxaparin to be at least as effective as heparin in reducing the occurrence of deep vein thrombosis while showing a tendency towards lower risk of bleeding complications; therefore, enoxaparin is recommended as thromboprophylaxis in patients undergoing major hip or knee surgery or suffering from multiple trauma.
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Results of 89 polycentric knee arthroplasties are assessed from 2 years to 7 1/2 years after operation. Seventy-two arthroplasties (81%) are considered to improve the mobility of the patient, with 17 arthroplasties producing no improvement. Infection after operation in 6 arthroplasties (7%) required arthrodesis of 3 arthroplasties. Loosening of prosthetic components occurred in 9 arthroplasties (10%).
Four hundred nineteen knees in 299 patients were examined preoperatively and at two years after polycentric total knee surgery. One hundred forty-three knees were in 109 patients with osteoarthritis. Two hundred seventy-six knees were in 190 patients with rheumatoid arthritis. Pain decreased significantly, use of aids decreased significantly, and distance walked increased significantly in both groups. Rheumatoid patients did not fare as well as osteoarthritics in the use of aids and distance walked. Osteoarthritic knees had proportionately more implant settling, implant loosening and reoperations than did rheumatoid arthritic knees.
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Seventy-five knees in 56 patients were examined preoperatively and at two years after geometric total knee surgery. Thirty-three knees were in 28 patients with osteoarthritis. Fourty-two knees were in 28 patients with rheumatoid arthritis. Pain was significantly decreased and the use of aids was significantly decreased in both groups. The distance walked increased significantly for the osteoarthritic group but not for the rheumatoid group. Rheumatoid patients did not fare as well as osteoarthritic patients in distance walked and use of aids. Knees with osteoarthritis had more evidence of lucent lines and implant loosening than did the rheumatoid patients.
A prospective follow-up using a standardized data recording form was carried out by independent, experienced orthopedic surgeons on a small number (116) of knees operated upon at The London Hospital in the period January 1, 1971 to October 31, 1973. An additional 93 knees have been operated upon at other hospitals and followed prospectively using the same data recording system. A total of 159 knees have been reviewed 2 to 4 years after operation. The complications specific to ICLH arthroplasty have been unremarkable and generally correctable. Two tibial components have sunk and have been revised at The London Hospital. The results show that ICLH arthroplasty has been used to correct satisfactorily flexion deformities up to 70 degrees, valgus deformities up to 45 degrees, and varus deformities up to 35 degrees. (Deformities of greater magnitude can be corrected but were not present among the knees in this study.) The operation may be said to be "worthwhile" with reference to pain in 94 per cent of the knees, with reference to the ability to walk in 80 per cent of the knees, and with reference to the range of movement in 71 per cent. Overall, 47 per cent of the knees had no complaint postoperatively, while a further 47 per cent were improved; thus for 94 per cent the procedure was "worthwhile."