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Muscle atrophy has been demonstrated in patients suffering from osteoarthritis of the hip, but little is known about muscular recovery after total hip replacement (THR). A total of 20 patients with unilateral osteoarthritis of the hip were assessed before, six months and two years after THR. The cross-sectional area and radiological density of the muscles of the hip, thigh, calf and back were measured using CT. We hypothesised that the muscles would not recover fully after operation. After two years comparison of the limb with the THR with the healthy limb showed that there was such a reduction in the cross-sectional area in iliopsoas (7.0%; p = 0.006) and the hip adductors (8.4%, p = 0.003) and in the radiological density in gluteus maximus (10.1 Hounsfield units; p < 0.001), gluteus medius/minimus (5.6 Hounsfield units; p = 0.011), iliopsoas (3.9 Hounsfield units; p < 0.001) and the adductors (2.4 Hounsfield units; p = 0.022). Thus, there was persistent muscle atrophy in muscles acting about the hip two years after THR. We suggest that an earlier operation or a more intensive rehabilitation may reverse these changes.

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AIM: The objective of this study is to improve our understanding of the mechanisms underlying the ageing- and gender-related muscle weakness. METHODS: Ageing- and gender-related differences in regulation of muscle contraction have been studied in knee-extensor muscles at the whole muscle and single muscle fibre levels in young and old sedentary men and women. In vivo knee-extensor muscle function was measured at slow (30 degrees s(-1)) and faster (180 degrees s(-1)) speeds of movement. Maximum velocity of unloaded shortening (V(0)) and maximum force normalized to cross-sectional area (CSA) [specific tension (ST)] were measured in single 'skinned' skeletal muscle fibre segments. RESULTS: Significant ageing- and gender-related differences were observed in muscle torque. A 33-55% ageing-related decline (P < 0.001) in maximum torque was observed irrespective of gender. At the single muscle fibre level, the ageing-related decline in knee-extensor muscle function was accompanied by a 20-28% decline in ST in muscle fibres expressing the type I MyHC isoform in both men and women, and a 29% decline in type IIa muscle fibre CSA, but the decreased fast-twitch fibre size was restricted to the men. Furthermore, in both men and women, V(0) decreased in muscle cells expressing the type I and IIa MyHC isoforms. CONCLUSION: The present results provide evidence of specific ageing- and gender-related differences in regulation of muscle contraction at the cellular level. It is suggested that these cellular changes have a significant impact on muscle function and the ageing-related motor handicap.

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A total of 63 women who had an operation for a fracture of the hip was randomly allocated to one year of treatment either with anabolic steroids, vitamin D and calcium (anabolic group) or with calcium only (control group). The thigh muscle volume was measured by quantitative CT. The bone mineral density of the hip, femur and tibia was assessed by quantitative CT and dual-energy x-ray absorptiometry and of the heel by quantitative ultrasound. Quantitative CT showed that the anabolic group did not lose muscle volume during the first 12 months whereas the control group did (p<0.01). There was less bone loss in the proximal tibia in the anabolic group than in the control group. The speed of gait and the Harris hip score were significantly better in the anabolic group after six and 12 months. Anabolic steroids, even in this moderate dose, given in combination with vitamin D and calcium had a beneficial effect on muscle volume, bone mineral density and clinical function in this group of elderly women.

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Late weight bearing on the operated leg after uncemented total hip arthroplasty may slow the patient's rehabilitation. The aim of this study was to find out whether 12 weeks of non-weight-bearing gait had any influence on passive hip extension, muscle strength, gait velocity, pain, and walking pattern during the first 24 postoperative weeks. There were no significant differences in results 24 weeks after surgery between 10 patients with late weight bearing and 11 patients with immediate weight bearing. As expected, however, there was a difference in muscle strength between the operated and the nonoperated leg. This study shows no evidence that late weight bearing after uncemented total hip arthroplasty implies any serious adverse effects on functional recovery after 24 weeks compared with immediate postoperative weight bearing.

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10 patients with major instability symptoms due to an acute anterior cruciate ligament injury were operated on with a bone-patellar tendon-bone reconstruction. Tibial condyle bone mineral density (BMD), bone ingrowth and changes in diameter in the tibia bone tunnel were studied with quantified computed tomography (QCT) postoperatively and after 1, 3, 6 and 12 months. We found no sign of bone ingrowth in the form of increased bone mineral density (BMD) in the bone tunnels in any of the patients. The tunnel diameter increased in all patients during the first postoperative months. After 1 year, 5 patients had a smaller diameter than at the first postoperative examination, 2 had the same diameter as immediately after surgery and 2 patients had a larger diameter. A sclerotic zone developed in all patients along the perimeter of the tunnel during the 3-6 months of follow-up. The BMD in the tibial condyle decreased at 3 months; it then increased, but between 6 and 12 months, it levelled out and was slightly lower than postoperatively. In conclusion, we found no growth of bone into the tunnel and tendinous part of the graft during the first postoperative year.

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We measured the levels of biochemical markers of bone formation and bone resorption in hip fracture patients preoperatively and after 6 and 12 months. Bone densitometry was done with quantitative computer tomography (QCT), dual-energy X-ray absorptiometry (DXA) and heel ultrasound. After 6 months, the biochemical markers of bone formation and bone resorption had increased. The levels remained high after 1 year and no change occurred between 6 and 12 months. We found no correlations between biochemical bone markers and bone density/stiffness on admission and change in bone mineral density (BMD) during the first postoperative year, despite the changes in bone markers and bone density. In our opinion, biochemical bone markers can not be used to predict bone loss in the individual patient after a hip fracture.

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Biochemical markers of bone formation and bone resorption were measured preoperatively, within 18 hours after a hip fracture (n 106) and bone mineral density (BMD) was measured with quantitative computer tomography (QCT), dual-energy x-ray absorptiometry (DXA) and heel ultrasound in 63 hip fracture patients. Patients with pertrochanteric fractures had more osteoporosis in all measurements than patients with femoral neck fractures. We found no differences in biochemical markers of bone formation or bone resorption in patients with femoral neck fractures and in those with pertrochanteric fractures. Correlations between biochemical bone markers and bone density, bone mass and stiffness on admission were weak.

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We measured total body bone density and body composition with dual energy x-ray absorptiometry in 43 elderly patients, 23 with hip fracture and 20 with coxarthrosis, after surgery and after 6 months. Insulin-like growth factor-1 (IGF-I), a polypeptide known to affect bone metabolism, and two of its binding proteins (IGFBP-1, IGFBP-3) were measured preoperatively and after 6 months. Normal serum IGF-I levels are dependent on adequate nutrition and normal secretion of growth hormone (GH). We found consistently lower levels of IGF-I and IGFBP-3 and a tendency to higher levels of IGFBP-1 in the patients with hip fractures, who also had a lower total body mass, lower fat mass and bone mineral density than the coxarthrosis group, indicating a more catabolic state in the patients with hip fracture, even 6 months after the trauma.

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This study was conducted to determine if bone and muscle loss is reversible in patients who had undergone total hip arthroplasty (THA) owing to necrosis of the femoral head after osteosynthesis for a displaced femoral neck fracture. The cortical bone mineral density (BMD), bone volume, bone mass, and muscle volume of the thigh and the BMD of the distal femur and proximal tibia were measured by quantitative computed tomography in 16 patients. Both extremities were measured just before reoperation. The measurements were repeated 3 and 6 months later. At reoperation, there was a mean 12% relative loss of bone mass and 23% loss of muscle volume in the middle femur on the fractured side compared with the uninjured side. In the distal femur and proximal tibia, there was a relative loss of BMD of 14% and 21% on the fractured side. Six months after reoperation, we found no change in bone mineral at any location on either side. The muscle of the thigh showed a gain in volume of 20% on the reoperated side but no change on the uninjured side. At the time of reoperation, we noted a marked bone and muscle loss on the fractured side. We failed to note any restoration of bone mineral after THA despite remobilization, which is expressed as an increase in muscle volume on the reoperated side. This study indicates that osteopenic bone has difficulties in adapting to patients' improved mobility after reoperation.

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Four hundred and thirty-seven patients with femoral neck fractures were studied to determine the value of serum albumin estimations on admission. Serum albumin is a good predictor of mortality, and patients with low levels should be given additional nutritional support. We found that the serum albumin level is not useful in predicting deep wound infection. The infection rate of 3% does not justify the use of antibiotic prophylaxis in general.

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We performed a prospective, longitudinal, quantitative computed tomography (QCT) study of bone mineral density (BMD), cortical bone volume, bone mass and muscle volume in 25 patients who were operated on with osteosynthesis because of a displaced femoral neck fracture. Both legs were scanned within 3 days after the fracture, and 3 and 6 months after the operation. The measurements were performed by a computer tomograph equipped for bone mineral densitometry. We found some side differences among the patients at the time of fracture, but none of the differences was statistically significant. After 6 months, we found reductions in BMD in the distal femur and proximal tibia on the fractured side of 11% and 19%, respectively, as well as a reduction in BMD of 7% in the proximal tibia on the uninjured side. We found no changes in cortical bone mass, either on the fractured femur or on the uninjured femur. The muscles of the thigh showed a loss of 9% on the fractured side, but a gain of 12% on the uninjured side. The findings of a bone loss in the distal femur and proximal tibia of the fractured leg and in the proximal tibia of the healthy leg, but no cortical bone loss in the middle femur on any side 6 months after the fracture, indicate that the cancellous bone is more sensitive to osteopenia. Moreover, this bone loss is interpreted as mainly a posttraumatic effect, since we also found a decrease in bone mineral on the uninjured side, despite a gain in muscle volume on that side, an overuse which was not sufficient to counteract the posttraumatic effect on the bone of the uninjured side.

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The cortical bone mineral density (BMD), bone volume, bone mass and muscle volume of the thigh, and the BMD of the distal femur and proximal tibia were measured quantified by quantitative computed tomography (QCT) after an operation for a displaced femoral neck fracture. Twenty patients were randomized to osteosynthesis or total hip arthroplasty (THA). Both legs were scanned after 18 months, and the operated side was compared with the healthy side. Clinical assessment was performed with a Harris hip score. A reference group of 9 patients, who had undergone THA because of arthrosis, was chosen. In the fracture patients, we found a 9% decrease in bone mass and muscle volume of the middle femur. The BMD of the distal femur and proximal tibia showed a more marked osteopenia. There was no difference in these parameters between the two groups. In the reference group of operated arthrosis patients, we did not find any differences between sides postoperatively. After the operation, the fracture patients had a lower Harris score than the arthrosis patients, and this was most pronounced among those who had undergone osteosynthesis. The finding of a marked osteopenia after a femoral neck fracture, irrespective of treatment, but no bone loss after THA because of arthrosis, implies that patients with a femoral neck fracture are more sensitive to osteopenia, and that the bone loss is not proportional to the operative trauma.

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80 patients underwent total hip replacement (THR) for primary coxarthrosis. In a randomized study, half of them donated 2 units of blood before operation. One unit was collected 4 weeks and one 2 weeks before the scheduled THR. All except 1 patient tolerated the predonations well. Total blood losses were similar in both groups. Additional bank blood was given in 7/38 in the predonation group, compared to 29/40 in the control group. Hemostatic parameters were studied in 10 consecutive patients in each group. Plasminogen activator inhibitor 1 (PAI-1), a possible risk parameter for thromboembolism, was significantly more increased postoperatively in the control group, which received only homologous blood. Platelet count, prothrombin complex, antithrombin III and von Willebrand factor antigen were significantly reduced and C reactive protein increased after surgery in both groups. We recommend predonation of 2 autologous units before a primary THR. In most cases, such predonation makes homologous blood transfusion unnecessary. The use of predonated blood causes no reduction of blood loss in THRs, but the increase in PAI-1 seen after homologous transfusions is avoided.

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OBJECTIVE: To assess the effects of intra-articular injections of hyaluronan on symptoms of knee osteoarthritis (OA). METHODS: Two hundred and forty patients with symptomatic, radiological knee OA were randomly assigned to treatment with weekly injections for five weeks with either 25 mg of high molecular weight hyaluronan or vehicle. Results were evaluated at weeks 1, 2, 3, 4, 5, 13, and 20 by visual analogue scales (pain, function, motion, activity), algofunctional index, and global evaluation by patient and investigator. Analysis was by "intention to treat', "per protocol', and area under the curve principles on unstratified patient groups and for patients stratified into four groups of equal size by age and baseline algofunctional index. RESULTS: No serious side effects were reported. At 20 weeks both treatment groups were improved compared with baseline, with no difference between unstratified groups treated with placebo or hyaluronan. Comparison of treatment groups stratified by age and baseline algofunctional index revealed a significant difference in favour of hyaluronan over placebo (pain, activity, algofunctional index, global evaluations by patient and investigator) for patients older than 60 years and with a baseline algofunctional index greater than 10. There was no clinically relevant difference between the two treatments for the other three stratified subgroups of younger age or fewer symptoms. Similar results were obtained by area under the curve, intention to treat, and per protocol analysis. CONCLUSIONS: Patients older than 60 years with knee osteoarthritis and with significant symptoms corresponding to an index of severity of knee disease of 10 or more, comprise the group most likely to benefit from treatment with intra-articular hyaluronan injections.

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We recorded temperature changes on the skin surface, subcutaneously and intra-articularly during cryotherapy after knee surgery by using Cryo-cuff compression dressings. Subcutaneous recordings on the contralateral knee were used as reference. 8 patients were examined. There was a reproducible decrease in skin temperature and subcutaneous temperature. Skin temperature had to be lowered to about 20 degrees C to obtain demonstrable intraarticular temperature changes.

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In a prospective randomized study we investigated 40 patients with functional instability due to old anterior cruciate ligament tears by using two different techniques for reconstruction of the ligament. 20 patients were randomized to reconstruction with use of a traditional medial bone-patellar tendon graft and 20 patients to a half-thickness patellar tendon graft augmented with the Kennedy Ligament Augmentation Device (LAD). At follow-up after 4 years, both groups were still improved concerning function scores and arthrometry. The use of the Kennedy LAD method, however, gave no more subjective or objective benefits than did the traditional method.

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In a randomized study 90 patients, operated on with a total hip or knee arthroplasty, were allocated to 1 of 3 different regimes, all including a reinforced single-use operating gown: (1) horizontal laminar flow ventilation and conventional clothes (cotton shirts and trousers) for all staff members, (2) horizontal laminar flow ventilation and occlusive garments (Klinidress) and (3) conventional ventilation and occlusive garments. Volumetric air sampling gave a low mean number of colony-forming units (< 10 cfu/m3) in the vicinity of the wound in all 3 groups. Laminar ventilation, with or without occlusive staff garments, resulted in less air contamination compared to conventional ventilation. During knee arthroplasty, the use of occlusive clothes in the laminar ventilation room, further reduced the number of airborne, bacteria-carrying particles to around 1 cfu/m3. No such reduction was seen during hip arthroplasty. We conclude that hip and knee arthroplasties can be performed in operating theaters with conventional ventilation when occlusive staff garments are used. However, laminar air flow ventilation in knee surgery, preferably in combination with occlusive garments, resulted in a substantially lower air contamination and should be preferred.

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We performed a prospective randomized study comparing fixation with biodegradable polyglycolic acid (PGA) rods (n 15) or screws (n 17) in 32 selected displaced supination-eversion fractures. Immediate postoperative weight bearing in a walking cast was encouraged. An exact reconstruction of the ankle mortise was achieved in 26/32 ankles. Roentgen stereophotogrammetric analysis (RSA) revealed rather small movements in the ankle mortise during fracture healing. A better stability was achieved by using screws. After 6 months the clinical results did not differ. One case of sinus formation and one with local effusion occurred; both healed without impairing the clinical result. To compare the results with a nondegradable osteosynthesis technique, a reference group of supination-eversion fractures previously operated on with cerclage-wires, staples and pins was used. RSA showed better fracture stability with nondegradable fixation. The clinical results, however, did not differ.

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Fifty-three patients with dislocated lateral malleolar fractures were randomly selected after operation for either active ankle movement and weight bearing in an orthosis or no ankle movement but weight bearing in a walking cast. At follow-up examinations after three, six, and 18 months, no differences were found between the groups except for a better linear analogue scale result at three months for the orthosis group. Active ankle movements do not improve the rehabilitation of surgically treated lateral malleolar fractures.

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