Acta orthopaedica. Supplementum最新文献

Congenital insensitivity to pain is a rare hereditary neuropathy. We present patients from a large family in Norrbotten, Sweden with a mutation in the nerve growth factor beta gene (NGFbeta). Using a model of recessive inheritance, we identified an 8.3-Mb region on chromosome 1p11.2-p13.2 shared by the affected individuals in the family. Analysis of candidate genes in the disease-critical region revealed a mutation in the coding region of the NGFbeta gene specific for the disease haplotype. All three severely affected individuals were homozygous for the mutation. The disease haplotype was also observed in both unaffected and mildly affected family members, but in heterozygote form. We have identified 43 patients, 3 homozygous and 40 heterozygous. The homozygous patients have a severe congenital form with onset of symptoms at an early age, most often affecting the lower extremities with insidious progressive joint swellings or painless fractures. Fracture healing was normal, but the arthropathy was progressive, resulting in disabling Charcot joints with gross deformity and instability. These patients lacked deep pain perception in bones and joints and had no protective reflexes, leading to gross bone and joint complications. They also had abnormal temperature perception but normal ability to sweat. There was no mental retardation. Clinically, they fit best into the group HSAN type V. Sural nerve biopsies showed a moderate loss of thin myelinated fibers (Adelta-fibers) and a severe reduction of unmyelinated fibers (C-fibers). 14 of the 40 heterozygous adult patients had mild or moderate problems with joint deformities, usually with only slight discomfort. Treatment was conservative with (if needed) different kinds of orthosis and in three cases joint replacement. Nine patients had neuropathy, and nine patients had no symptoms. In congenital disorders like these, it is important to evaluate the age and also the slowly progressive nature, when considering treatment. There is an increased risk of growth disturbances in the very young. The orthopedic operations should therefore be planned from a long-term point of view, but patient education and orthosis are cornerstones in the treatment--to delay the development of neuropathic arthropathy. Arthrodesis, limb lengthening and spinal decompression with fusions are the only elective procedures that seem reasonable. This Norrbottnian disease is also interesting as a model system for the study of pain.

Chronic neck pain, a common cause of disability, seems to be the result of several interacting mechanisms. In addition to degenerative and inflammatory changes and trauma, psychological and psychosocial factors are also involved. One common type of trauma associated with chronic neck pain is whiplash injury; this sometimes results in whiplash-associated disorder (WAD), a controversial condition with largely unknown pathogenetic mechanisms. We studied the prevalence of chronic neck pain of traumatic and non-traumatic origin and compared the prevalence of, sociodemographic data, self-perceived health, workload and chronic low-back pain in these groups. In a ready-made questionnaire (MONICA study), we added questions about cervical spine and low-back complaints. 6,000 (72%) completed a self-administered questionnaire. 43% reported neck pain: 48% of women and 38% of men. Women of working age had more neck pain than retired women, a phenomenon not seen in men. 19% of the studied population suffered from chronic neck pain and it was more frequent in women. A history of neck trauma was common in those with chronic neck pain. Those with a history of neck trauma perceived their health worse and were more often on sick-leave. About 50% of those with traumatic and non-traumatic chronic neck pain also had chronic low-back pain. We assessed the subjective and objective neuropsychological functioning in 42 patients with chronic neck pain, 21 with a whiplash trauma, and 21 without previous neck trauma. Despite cognitive complaints, the WAD patients had normal neuropsychological functioning, but the WAD group especially had deviant MMPI results-indicating impaired coping ability and somatization. WAD patients had no alterations in cerebral blood-flow pattern, as measured by rCBF-SPECT and SPM analysis, compared to healthy controls. This contrasts with the non-traumatic group with chronic neck pain, which showed marked blood-flow changes. The blood-flow changes in the non-traumatic group were similar to those described earlier in pain patients but--remarkably enough--were different from those in the WAD group. Chronic neck pain of whiplash and non-traumatic origin appears to be unique in some respects. A better understanding of the underlying pathological mechanisms is a prerequisite for prevention of the development of such chronic pain syndromes and for improvement of the treatment of patients with severe symptoms.

Background: There is no consensus regarding outcomes assessment in spine patients. When using Health-Related Quality of Life (HRQoL) in assessing outcomes of treatment, normative data for different diagnoses are needed to allow comparisons between existing and future studies. The most used generic instrument for HRQoL evaluation in spine pathologies is SF-36. There is no standard definition of important differences in spine surgery patients and no standard reference for minimal clinically important difference.

Objective: The overall aim of this thesis was to increase understanding of some aspects of outcome measurement in patients operated on for lumbar spine problems using existing prospective data available at the spine section of the Orthopedics Department of the University of Lund, and, moreover, to explore potentials and weaknesses in the methodology of retrospectively analysis of prospectively collected observational data.

Methods: A systematic web-search and review of the literature and a retrospective analysis of prospective cohort data collected within the data collection protocol in use by the Swedish Spine Register. Since 1993 all persons undergoing elective lumbar surgery at the spine section of the Orthopedics Department of the University of Lund were included in the prospective registration protocol either in its first version (1993-1997), which was the source of data for paper III, or in its revised version after 1998. Initial information at baseline (the day before surgery) included age, sex, smoking habits, duration of preoperative back and leg pain in months, duration of preoperative sickleave in months, number of previous operations, patient's working status, diagnostic techniques pre- and postoperatively VAS scores analgesic intake, walking distance. Postoperatively, change in leg and back pain, respectively, was recorded on a 5-point Likert Scale as compared to preoperative status, patient satisfaction was recorded on a 3-point Likert Scale.

Results: The number of proposed outcomes, outcome scores, outcome instruments is incredibly high: no new HRQoL instruments specific for LBP are needed. The data collection protocol of the Swedish Spine Register studied can reliably detect postoperative improvements between large groups of patients such as in a Register. Pain intensity measured on the VAS correlates significantly to other indicators of perceived pain, but correlation is not as strong as it could be if they were all measuring the same construct. HRQoL as measured by SF-36 in patients scheduled for lumbar spine surgery showed a pronounced reduction compared to normal and LBP population. The use of norm-based scoring for SF-36 can help interpretation and simplify graphic representation of the findings. SF-36 outcomes 1-year after surgery for lumbar spine disorders are improved, although other factors or natural history could contribute to

Aims: To evaluate the outcome of different types of polyethylene, bone cements and one design of uncemented fixation with porous and ceramic coating using radiostereometry, bone densitometry, conventional radiography and clinical parameters.

Materials and methods: Study I: 201 patients were extracted from 5 prospective randomised studies to evaluate femoral head penetration at two years with radiostereometry in four basic designs, cemented Lubinus and Reflection cups, uncemented Trilogy and Reflection cups. Studies II and III: 60 patients (61 hips) were randomised to receive either highly cross-linked or conventional all PE cups. 32 patients with bilateral arthrosis received hybrid THA with highly cross-linked PE on one side and conventional on the contra lateral side. Femoral head penetration and the migration of the cups were evaluated with radiostereometry in the supine and standing positions. DEXA and conventional radiography were used to evaluate the bone mineral density and radiolucencies around the cemented acetabular component. Studies IV and V: 90 patients (97 and 96 hips respectively) were stratified depended on age, gender, diagnosis and preoperative BMD to create 3 main groups of socket fixation. In the first group fluoride containing cement was used, in the second group Palacos cum Gentamicin and in the third hybrid THA with porous coated HA/TCP cup. In the hybrid group the fixation of the femoral component was again randomised to either of the two cements. The results on femoral and acetabular sides are presented separately in studies IV and V, respectively.

Results: Study I: Cups with polyethylene sterilized in EtO had almost twice the proximal and 3D penetration rates compared with gamma-sterilized polyethylene. Regression analysis showed that the type of sterilization, age and weight was the most important factors affecting the penetration rate. Studies II and III: In the cemented study the proximal penetration was lower in the study group independent of position at 3 years, while in the hybrid study the penetration was lower in the study group only in the supine position at 2 years. The migration of the cup did not differ between the plastics in both studies. At 2 years the periprosthetic radiolucency and BMD did not differ significantly between the 2 types of PE used in the cemented study. Study IV: The subsidence of the stem did not differ between the groups, but the periprosthetic BMD decreased more in fluoride cement group at 2 years. Conventional radiography revealed higher progression of radiolucent lines in the Palacos group, but only in one region. Study V: The proximal migration of the cup was almost similar in all three groups. The three dimensional migration was increased in patients with osteoporosis. Postoperative radiolucent lines tended to disappear with use of porous coating covered with HA/TCP.

Conclusions: Study I: EtO ster