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The serum osteocalcin (BGP) concentration and alkaline phosphatase (AP) activity were measured prospectively during the healing phases of crural fractures in 15 patients. They were divided into two groups, the time of union of the fracture being under (group 1) or over 16 weeks (group 2). The mean values of BGP and AP were somewhat higher from the outset in the group 1 than in the group 2, but the difference was not significant. A significant increase in BGP and AP (P less than 0.05) was evident in both groups at 6 weeks. In cases with undisturbed healing of fractures (group 1) the values of serum BGP and AP then declined towards the values at the time of accident. Contrary to this, in group 2 both the values of the serum BGP and AP were still at a significantly higher level than those at the day of the fracture. However, no significant difference in the serum BGP or AP was seen between the two groups at 6 or 12 weeks. The results support some earlier ones: the changes in serum BGP and AP may provide a prognostic indicator for consolidation of a fracture.

The healing of a standardized defect of the supraspinatus tendon in a time-related series on rabbits was monitored with arthrography and simultaneous determination of the intra-articular hydrodynamic pressure of the glenohumeral joint. All normal glenohumeral joints produced a biphasic pressure versus volume curve. Rupture of a normal glenohumeral joint occurred at a pressure level of 140-170 mm Hg and was located in the area around the biceps tendon sheath. In joints with a defect of the supraspinatus tendon, leakage of the contrast medium was evident up to the sixth week, at an intra-articular pressure varying from 40 to 100 mm Hg. After week 6, no leakage of the cuff was seen during the determination of the intraarticular pressure. This was in accordance with the histological findings: the defect was covered with solid scar tissue from the ninth week onward. Resistance to hydrodynamic intraarticular pressure proved a reliable method of determining the strength of the healing of the supraspinal defects.

Symptomatic (Stage II) impingement of the rotator cuff against the coracoacromial arch has been treated with anterior acromioplasty in 60 shoulders in 56 patients. Patient selection is crucial. Arthrography of the shoulder was routinely included in the preoperative diagnostic tools to rule out a tear of the rotator cuff. Since acromial shape may play a role producing a resistant impingement syndrome, special attention should be paid to patients with Type III of acromial inclination. The surgical procedure should include a thorough examination of the subacromial space as a whole, taking notice of all pathologic findings in the subacromial arch as well as in the underlying soft tissues. Restoring subacromial clearance, the patients were relieved of their symptoms. The result, rated according to the functional assessment of Neer, was excellent or satisfactory in 73%. Failure to recognize the associated bony as well as soft-tissue subacromial lesions was, however, a frequent cause of failure of surgical decompression operations.

A one-stage method of treating infected non-union of a fracture of the femoral shaft is described. The method involves excision of dead and infected tissue, resection of bone ends, cancellous bone grafting and fixation with an external frame. Four out of five cases were successful within 7 months.

The patients with xanthomas bilaterally in the Achilles tendons associated with type-II hyperbetalipoproteinaemia are reported. Both patients had elevated serum cholesterol, normal or slightly elevated serum triglycerides and an electrophoretic pattern of elevated beta and pre-beta lipoproteins. Subtotal resection of the tumours was found to be satisfactory in both patients with less risk of complications when compared with the earlier methods reported with total excision and reconstruction of the defect with fascial grafts. The early recognition and evaluation of the patients with hyperbetalipoproteinaemia is important because it is associated with an increased incidence of atheromatous coronary disease, often manifestated at an early age. That is why surgical interventions of tendon xanthomas must be connected with adequate medical treatment of the basic disorder in lipid metabolism

Segmental blood pressure criteria for below-knee amputations were assessed retrospectively. 40 patients underwent 44 below-knee amputations for advanced lower limb ischaemia. Preoperative systolic blood pressure measurements using a Doppler device as a distal sensor were performed on 31 limbs to be amputated. Healing occurred in all limbs with calf systolic pressures of 68 mmHg or more and distal thigh systolic pressures of 100 mmHg or more. With calf pressures below 35 mmHg and distal thigh pressures of 60 mmHg or less, all amputations failed. Diabetes did not affect the pressure criteria except for one obvious case with mediasclerosis. It appeared that pressure data could be used to improve the preoperative assessment of the amputation level.

Dextranomer (Debrisan, Pharmacia, Uppsala, Sweden) is synthetized by cross-linking of dextran chains with epichlorohydrin. It is an insoluble hydrophilic substance which is suitable for topical treatment of secreting wounds, such as burns. Thirteen patients with 17 burned hands were treated. The result of the treatment - decrease in pain, healing time and improved hand function - was registered clinically. No crust was formed. The risk of permanent restriction in range of movements decreased, since the treated hands were soft and mobile throughout the entire period of treatment. All hands treated recovered full mobility. Physiotherapy could be performed daily. No infection appeared because exudate and bacteria were continuously removed from the treated area. Pain rapidly decreased. No side reactions were observed.

During a follow-up period of 16 weeks in 18 pigs, macroscopical and histological studies revealed invasion of fibroblasts and mesenchymal cells around the carbon fiber prosthesis inserted to replace the ACL but scarce tissue ingrowth into the prosthesis proper. There was no adherence of the carbon ligament onto the bony channels. The peak tensile strength of the reconstructed ligament was about one third of the paired normal ACL ligament during the 16 week experiment.

Experimental osteotomies were made in 35 rabbit tibiofibular bones and fixed with rigid stainless steel osteosynthesis plates (DCP/ASIF). The radiographic and histopathologic appearances in the healing osteotomies and adjacent bone were analysed at intervals from 3 up to 24 weeks postoperatively. Radiologically the osteotomy had closed at 9 weeks and microscopically this could be confirmed as longitudinal orientation of the cutter heads across the osteotomy gap with longitudinal orientation of the bone structure. The healing of the osteotomy was accompanied by gross structural changes in the adjacent cortical bone with loss of intracortical and subendosteal osteons, cementing lines and intermediate tissue between the osteons. This was characterized by decreasing attenuation of the cortical bone after healing of the osteotomy and should clinically be regarded as an indication for removal of the implant.

Two cases are reported where the common femoral artery ruptured during hip replacement surgery. In both cases only the intimal and medial layers of the artery were injured, without profuse bleeding during the operation. The diagnosis of this type of lesion of the arterial wall can be delayed. The use of non-invasive Doppler ultrasound techniques for verifying arterial injury proved to be effective and the presence and degree of arterial insufficiency was easily estimated from distal blood pressure measurements. In both cases the femoral artery was then exposed with no preoperative angiography and the arterial damage was successfully repaired. If the classical signs of acute ischaemic lesion are observed soon after hip replacement operations, the possibility of an acute arterial lesion must be kept in mind.

Rigid intramedullary nailing was used in 75 rabbits to stabilize a transverse osteotomy of the midshaft of the tibia. In 36 additional rabbits intramedullary nailing was performed without osteotomy. No additional external immobilization was used postoperatively. After removal of the nail the mechanical strength of the tibiofibular bones was tested torsiometrically in 30 osteotomized and 18 non-osteotomized animals from 3 to 24 weeks after the operation. At 3 weeks the torsional load fractured all osteotomized bones through the osteotomy line. At later stages a spiral fracture occurred either crossing or close to the osteotomy area, usually distal to the tibiofibular junction. The increase in mechanical strength of the osteotomized bones reached a maximum at 6 weeks and then decreased. The strength of the non-osteotomized nailed bones also decreased slightly. The results suggest that rigid intramedullary nailing, although providing good conditions for early consolidation of experimental osteotomy, leads secondarily to deterioration of the mechanical properties of tubular bone.

The radiographic findings and arthrographic image of the intertubercular groove and the biceps tendon were analysed in 143 patients with chronic shoulder pain. Forty-eight patients had been operated on, and of these 33 had tendinitis, caused by attrition in a narrow intertubercular groove in 17 cases, by medial dislocation of the biceps tendon in 11 cases, and by impingement associated with rupture of the rotator cuff in five cases. Plain radiographs revealed degenerative changes in the walls of the groove in half of the patients with biceps tendinitis. A shallow groove was seen in cases of medial dislocation of the biceps tendon, but also in many with a normal tendon. The arthrogram, however, showed whether a shallow groove was associated with dislocation of the tendon. In patients with attrition tendinitis the groove had a depth of 4.8 mm or more or an inclination of the medial wall of 58 degrees or more. Radiographic measurements of the dimensions of the intertubercular groove may provide valuable information on the state of the biceps tendon.

Transverse osteotomies of the midshaft of the tibia in 75 rabbits were stabilized with intramedullary nails which prevented rotational instability. In a further 36 animals intramedullary nailing was performed without preceding osteotomy. The animals were able to move freely immediately after the operation without any supporting case or splint. The structural changes in the bones were analysed radiographically 3 to 24 weeks after the operation. Fracture repair was accompanied by moderate periosteal callus formation and remodelling of the callus was seen from 9 weeks on. A sleeve of new endosteal bone surrounding the nail was found after 12 weeks. Porotic transformation of the diaphyseal cortical bone was seen in both osteotomized and non-osteotomized bones from 12 weeks onwards. It is concluded that intramedullary nailing provides favourable conditions for fracture repair and enables accurate radiographic assessment of the healing. Attention is focused on the causes and features of secondary porotic transformation of the cortical bone after intramedullary nailing.

The supradiaphragmatic vena cava of the rat was transplanted to the abdominal aorta in syngeneic recipients. The cells and the connective tissue matrix of these grafts were studied 3 days to 12 weeks after transplantation by immunofluorescence staining of the cytoskeletal proteins desmin, vimentin, and myosin. The matrix proteins, collagen Types I and III, laminin, fibronectin, and fibrin(ogen) were similarly demonstrated. Blood coagulation Factor VIII was used as a marker for endothelial cells. Inflammatory cells invaded the graft during Week 1, but later on the grafts were crowded with cells containing vimentin. Intimal thickenings developed already after 1 week. Smooth muscle cells containing desmin proliferated in these thickenings. After transplantation collagen Type I increased in the graft, but collagen Type III rather decreased. During the phase of intense proliferation of smooth muscle cells the media contained a rich matrix of diffusely distributed laminin. The laminin of older grafts was confined mostly to the subintimal zone and to the intimal plaques.

The purpose of the present study was to compare ultrasonographic signs with macroscopic and histological findings in lesions of the rotator cuff and the biceps tendon. Twenty-six shoulder joints from 10 male and 3 female cadavers, ranging in age from 40 to 89 years (mean 65.9), were examined with a linear array real-time ultrasonographic scanner provided with a 7.5 MHz transducer. Arthrotomy and histological preparations were made after ultrasonography. Thinning and discontinuity of echogenic homogenicity of the tendons of the rotator cuff were the most reliable ultrasonographic signs of a total tear of the tendon, but focal hyper- and hypo-echogenic changes of the tendons of the rotator cuff were unreliable criteria. Partial tears of the rotator cuff were difficult to determine with static ultrasonograms. Ultrasonography readily revealed discontinuity of echogenic homogenicity of the biceps tendon as a sign of a rupture of the tendon, which was commonly associated with rotator cuff tears.

The effects of systemically administered calcitonin (CT) on granulation tissue development were compared using viscose cellulose sponges as wound model in the rat. The ingrowth of new granulation tissue was analyzed for the contents of various connective tissue components (total nitrogen, hydroxyproline, DNA, and RNA) and for the differential counts of the cells infiltrating the sponges. The results indicate that up to 4 weeks postoperatively (p.o.) CT did not affect the net amount of collagen, measured as hydroxyproline, total nitrogen, aminosugars nor the dynamics of differentiation and viability of the invading cells. The present observation that CT has negligible effects, if any, on the early stages of connective tissue formation and on the cell population indicates that surgical procedures could be carried out safely during systemic CT therapy without an increased risk of wound complications.

The effects of systemically administered calcitonin (CT) on fracture healing were analyzed in an experimental study on rats. The healing of a fracture was followed from 3 days up to 9 weeks postoperatively. Half of the rats in each age group were given daily CT 10 MRC-U/kg body wt s.c. Mechanical properties of the healing tibial fractures (tension strength) as well as various connective tissue components of the callus tissue were analyzed. No difference in the radiological or microscopical appearance of the fractures was detectable between the animals receiving CT and the controls. In the biochemical analysis matrix production as assessed from the concentrations of nitrogen, hexosamines, and hydroxyproline within the callus followed the usual lines of undistributed fracture union without any difference between the groups with and without CT. No differences could be detected in the mineralization of the callus between the specimens from animals receiving CT and those without. The tensile strength values of the fractures increased almost linearly up to 9 weeks. At 1 week the tensile strength values for fractures union in the animals without CT were approximately 50% higher, but later on no differences could be detected between the groups. These results indicate that although in the early phases of long-term CT therapy collagen synthesis may be impaired, there will be no effect on the net content of collagen or calcifying tissue in the callus or on the mechanical strength of healing fractures.

The presence of the connective tissue components fibronectin and collagen types I and III have been demonstrated by immunohistological methods after reconstruction of the anterior cruciate ligament of pigs with carbon fibre. The carbon fibre ligament prosthesis was covered with pediculated fascia lata. During the initial 16-week period, fibronectin was seen both in the surrounding fascial layer and between the carbon fibres of the substitute. Type III collagen was also found, especially in the fascial layer, but collagen was absent from the carbon fibre prosthesis and was seen only in the fascial layer. Results indicate that the tissue in the 'neoligament' after carbon fibre reconstruction consists mostly of granulation tissue with a high amount of fibronectin, and type III collagen from mesenchymal cells without sufficient amount of type I collagen with tensile strength to withstand subsequent mobilization and rehabilitation.

Thirty-eight patients had a Neer II replacement for rheumatoid arthritis of the shoulder. The average age at operation varied from 23 to 68 years. The average follow-up was 20.9 months. Forty shoulders were free of pain and function was reasonable in 21. Overall evaluation showed an excellent or satisfactory result in 15, 16, were acceptable and 10 poor. The most frequent radiological finding was upward subluxation which was present in 20 shoulders. An incomplete radiolucent zone was found around the glenoid component in 32% and around the humeral in 5%; there was no gross loosening.

Bone repair was studied in the rabbit tibiofibular bone after a midshaft transverse osteotomy stabilized by external fixation and heavy compression. Both subendosteal and subperiosteal callus formation with concomitant contact healing were observed within 3 weeks, and were further succeeded by subendosteal resorption and increased porosis resulting in atrophy of the cortical bone. Subjected to the torsion test, the bones exhibited restoration of strength within 3 weeks, with maximal energy absorption and elasticity at 6 weeks. The failure of the osteotomy in the torsion test, with radiographic visibility of the osteotomy, characterized the soft-tissue type of behavior of the bones. Hard-tissue like behaviour of the bones with resistance to torsion at the osteotomy site and radiographic obliteration of the osteotomy line occurred by 12 weeks, indicating complete union of the osteotomy. Our experiments demonstrate that elastic external fixation is preferable to the rigid compression plate.

Calcium and hydroxyproline content of intact rabbit tibio-fibular bone was assay chemically 1 day to 36 weeks after compression and neutral plate fixation with a 4-hole stainless steel ASIF/DCP plate. During the first three postoperative weeks calcium content of the cortical bone decreased by an almost significant amount (P less than 0.05); thereafter, calcium values remained subnormal but did not differ significantly from initial postoperative values. Hydroxyproline content increased steadily throughout the experiment (P less than 0.001). The changes in chemical composition of the bone were of the same magnitude after compression and neutral plate fixation. The results suggest that the cancellous transformation of cortical bone, known to take place under rigid plates, reflects an active remodelling process of the bone in which the calcium and hydroxyproline content changes only slightly.

Results after the operative treatment of 39 total (Type III) acromioclavicular (AC) dislocations are reported. The operation consisted of suture of the acromioclavicular and coracoclavicular ligaments and transfixion of the AC joint with an AO/ASIF malleolar screw passed through the acromion into the lateral end of the clavicle. The screw was removed at an average of six weeks after the operation. In 36 patients re-examined after a mean of 4 years, the overall results were good in 92 per cent of cases. The range of flexion and abduction was excellent (over 170 degrees) in 90 per cent. Stress radiographs revealed persisting subluxation of the AC joint in 6 patients and persisting dislocation in 1. Signs of osteoarthrosis were seen in 4 patients and signs of osteolysis in 12. Radiological signs of osteolysis correlated well with incongruity of the AC joint but not with the clinical function. Radiological signs of osteoarthrosis in the AC joint, however, correlated with a poor clinical result: all patients with a fair or poor clinical result had signs of osteoarthrosis in the AC joint. Except for one, all patients returned to their preoperative occupations within an average of two months.

The purpose of this study was to analyze arthrographic imaging of the structures of the shoulder joint when using either sodium meglumine metrizoate or iopamidol as a contrast medium. Two hundred and ten patients underwent single-contrast shoulder arthrography. In patients with a full-thickness tear of the rotator cuff, both contrast agents reliably revealed this lesion. However, in patients with a full-thickness rotator cuff tear, the biceps tendon could be demonstrated more readily with iopamidol, which is a non-ionic contrast medium.

Cortical and cancellous interposition grafts, with rigid plate fixation, in the tibiofibular bones of 130 rabbits were followed radiographically for one year. The cancellous grafts healed earlier, but by 12 weeks both graft types had been incorporated, the distal host--graft interface being the last to heal. Progressive cancellous transformation in both the graft and host bone led to an increased over-all bone diameter, a widened medullary canal and a thinned porotic wall.

The initial treatment of complicated fractures several days old when first seen in Afghan war wounded is reported for 52 limbs in 47 patients. External fixation was the method of choice for stabilizing fractures in adults. In children, traction and plaster-of-Paris were preferred. In 30 cases (58 per cent) tissue damage was classified as moderate. With radical wound toilet and delayed closure, infection could be controlled in most of these limbs. In 15 fractures (29 per cent) there was severe laceration and exposure of bone. After operation, deep infection persisted in three-quarters of these cases and the fate of these limbs often seemed doubtful. The patients usually refused amputation. However, of seven limbs (13 per cent) in which the fracture was associated with an arterial injury, only one could be saved. The brief period of observation of only 11 weeks does not permit assessment of time to healing, frequency of late osteitis or definitive amputation rate. It seems, however, that in spite of the lack of any proper first aid for these severe injuries, a functional limb could be salvaged in over two-thirds of the cases, even with our modest resources.

The injuries seen in 200 Afghan war wounded in the International Committee of the Red Cross (ICRC) hospital in Quetta are reported. Evacuation took several days and no proper initial first aid was available. Therefore few of those reaching us had serious multiple injuries. The anatomic distribution of wounds was remarkably similar to that seen in other conflicts: 38% of the injuries were caused by bullets, 50% by fragmentation weapons, and 10% by mines. Two thirds of the patients had limb injuries. Of all wounded, patients with fractures of long bones needed the greatest number of repeated operations and the longest hospitalization time. Twenty-five patients had abdominal or perineal wounds and 12 needed laparotomy. Of 25 with head injuries 14 had penetrating brain trauma. Thoracic, vascular, and burn injuries were rare. The eight patients with spinal cord injury could fortunately be referred to the ICRC rehabilitation center in Peshawar within a week. Wound sepsis was the major problem due to the extraordinarly long delay in the initiation of treatment. In spite of the often grossly infected wounds, radical debridement usually led to good recovery for most patients, with a hospital mortality rate of only 2.5%.

During the period 1968-1973 70 patients with 79 basal cell carcinomas were admitted to the Division of Plastic Surgery, Helsinki University Central Hospital. Many of these tumours were primarily treated elsewhere or sent to plastic surgery at the stage when radical surgery was no longer possible. 31 of these primary tumours developed into 70 recurrent tumours. Twelve tumours had highly destructive features. In order to evaluate the frequency of various histological growth patterns in recurring basal cell carcinoma a retrospective study was performed. It became clear that the histological growth pattern was no guide to the rate of recurrence and prognosis. The histological growth pattern of the sclerosing type was found more often in recurrent tumours, possibly a consequence of previous radiotherapy. The incidence of radiotherapy as an initial method of treatment was higher in the group of patients with primary tumours who developed recurrences. Inadequate excision margins were found more often in the same group.

The purpose of this study was to analyse the factors having an influence on the arthrographic imaging of the biceps tendon. The study comprised 174 patients suffering from chronic shoulder pain. They underwent conventional shoulder arthrography with sodium meglumine metrizoate or metrizamide as a contrast medium. In the patients with a full-thickness tear of the rotator cuff, the biceps tendon sheath failed to fill with contrast medium more often than in those with an intact tendinous cuff. Metrizamide filled the biceps tendon sheath more readily than sodium meglumine metrizoate in patients with a full-thickness tear of the rotator cuff. The volume of the contrast medium injected had no influence on the imaging of the biceps tendon.

The influence of a rigid plate on the structure of intact tubular bone was studied in forty adult rabbits using a four-hole commercial-steel DCP-ASIF plate attached to each tibiofibular bone, with and without compression. The morphological changes in the bone underlying the plate were examined and were assessed quantitatively at one day to thirty-six weeks after operation. The rigid plate induced porotic changes in the cortical bone, which were evident three weeks after the operation and increased rapidly between twelve and eighteen weeks. At thirty-six weeks, resorption cavities occupied 40.6 per cent of the cortical wall of the bones plated with compression and 41.2 per cent of the wall of those plated without compression. The changes were visible slightly earlier in the presence of compression. A rigid plate brought about a statistically significant increase both in the outer diameter of the bone and in the diameter of the medullary space as a result of subperiosteal new-bone formation and concomitant subendosteal bone resorption.

Lesions of the biceps tendon have been studied with plain radiographs and arthrograms of the intertubercular groove. Sometimes, however, especially when the rotator cuff has a full-thickness tear anteriorly, the sheath of the biceps tendon fails to fill with contrast medium, thus preventing diagnosis of dislocation of the tendon. To solve this problem the authors have tried sonography of the biceps tendon. The suitability of sonography for examining the intertubercular groove and the biceps tendon was assessed in ten volunteers. Thirty patients with chronic shoulder pain were subsequently studied by radiography, arthrography, and sonography. The observations made with these examinations were compared, and in 21 of the patients who were treated by operation with the surgical observations as well. Sonography seemed to provide accurate information about the configuration of the intertubercular groove and the position of the biceps tendon. The technique could be used to show dislocation of the tendon in cases in which the tendon sheath is not visualized in arthrography. Tenderness and the site of this in relation to the anterior upper end of the humerus could also be verified with sonography.

The surgical pathology and clinical results of 78 reconstructions of chronic rotator cuff tears were reviewed retrospectively. The predominant complaint preoperatively was chronic pain with impaired shoulder function, resistant to repeated conservative treatment. Results according to a functional assessment were excellent or satisfactory in 71% of the patients, unsatisfactory in 12%, and failed in 17%. Relief of pain including night pain and pain with activity was obtained. Surgery should include a thorough exploration of the rotator cuff and the adjacent tissues. Accompanying problems, including biceps tendon disorders or impingement factors, must be recognized and treated at the time of the reconstruction procedure. Repair of the torn rotator cuff and treatment of concomitant lesions are effective operative procedures when symptoms are persistent and fail to respond to conservative treatment.