Resúmenes de los artículos seleccionados.

[Generalidades]

Cardona, JM. & Pastor, E.:
Calcitonin versus etidronate for the treatment of postmenopausal osteoporosis:
a meta-analysis of published clinical trials.
Osteoporos Int 1997, 7, 3:165-74.
Abstracts: This review examines the evidence on the efficacy of calcitonin and etidronate in the prevention of
osteoporosis and osteoporotic fractures. MEDLINE was searched for clinical trials calcitonin or etidronate and
reviews of the treatment of postmenopausal osteoporosis. The reference sections of the papers retrieved were again
searched for trials on the treatments of interest. Two people independently collected data from the trials that met the
inclusion criteria of the study. Weighted means in the change in bone mineral density (BMD) and differences in
vertebral fracture rates were computed for calcitonin and etidronate separately. The existence of publication bias
was investigated by funnel plots of effect size against sample size. Eighteen clinical trials and calcitonin and six with
etidronate were included in the meta-analysis. The pooled change in vertebral BMD at the end of the studies was
1.97 (95% CI 1.77 to 2.17) with calcitonin and 3.20 (95% CI 2.92 to 3.48) with etidronate. Pooled change in
proximal femur BMD was 0.32 (95% CI -0.27 to 0.91) with calcitonin and 2.42 (95% CI 2.16 to 2.68) with
etidronate. The aggregated number of vertebral fractures prevented by the treatment was 59.2 per 1000 patient-years
(95% CI 55.1 to 63.3) for calcitonin and 28.3 (95% CI 26.2 to 30.4) for etidronate. With the available evidence we
cannot establish the superiority of either of the two drugs for the treatment of postmenopausal osteoporosis. The
clinical trials are particularly lacking in data on hip fracture, the most important consequence of osteoporosis. In this
situation consideration of the relative costs of the drugs is prominent.

Fernberg, JO., Wiklund, T., Monge, O., Hall, KS., Saeter, G., Alvegard, TA. & Strander, H.:
Chemotherapy in soft tissue sarcoma. The Scandinavian Sarcoma Group experience.
Acta Orthop Scand Suppl. 1999 Jun, 285: 62-8.
Abstracts: The first chemotherapy study of soft tissue sarcoma (STS) by the Scandinavian Sarcoma Group was
started in 1981 (SSG I). It evaluated the single agent adjuvant doxorubicin in a randomized setting in patients with
high-grade STS. No improvement was noted in the overall survival or disease-free survival rate. More intense
chemotherapy was thereafter (1991-1994) evaluated in a phase 2 study, introducing ifosfamide and a continuous
infusion of etoposide with growth factor (SSG X). The response rate of previously untreated patients was high
(42%), but complete remissions were few. Analysis of patients undergoing surgery after preoperative chemotherapy
suggested an increased survival. A recent meta-analysis of adjuvant chemotherapy for localized resectable STS in
adults, including the SSG I trial, indicated a better disease-free survival and possibly improved overall survival
(Thierny et al. 1997). At present, we are studying whether such a benefit can be shown in patients with high-risk
prognostic criteria by giving adjuvant ifosfamide and doxorubicin treatment after primary surgery (SSG XIII). In the
latter SSG study, started on July 1, 1998, the adjuvant therapy is evaluated in a phase 2 study in selected patients
with high-grade STS and other unfavorable prognostic factors.

Gong, G., Stern, HS., Cheng, SC., Fong, N., Mordeson, J., Deng, HW. & Recker, RR.:
The association of bone mineral density with vitamin D receptor gene polymorphisms [].
Osteoporos Int. 1999, 9, 1: 55-64.
Abstracts: A recent meta-analysis of 16 publications suggested that bone mineral density (BMD) is not associated
with vitamin D receptor (VDR) gene polymorphism (VDRGP) at the 0.05 significance level when a study with
genotyping mistakes is excluded. We wished to determine whether 'positive' findings supporting the BMD-VDRGP
association may be explained by chance, and what factors affect the outcomes of these studies. Seventy-five articles
and abstracts on the association of VDRGP with BMD and related skeletal phenotypes published before January
1997 were identified. Twenty-three of 67 (34.3%) studies on spinal BMD and 22 of 51 (43.1%) on femoral neck
BMD had found a BMD-VDRGP association at p < 0.05, significantly (p = 7 x 10(-14) for spinal BMD, p = 9 x 10(- 16)
for hip BMD) higher than the expected 5% false positive rate under the null hypothesis of 'no association'.
'Positive' results were more frequently observed in studies on females before the menopause than those on females
after the menopause (p < 0.02) or on male and female subjects combined (p < 0.05) when skeletal phenotypes at any
bone sites were considered. The 'positive rate' among studies was also influenced by the age range of subjects
studied and by the inclusion of subjects with osteoporosis. It is concluded that: (1) BMD is associated with VDRGP
with high levels of confidence and (2) non-genetic factors and genetic heterogeneity interfere with the detection of
the effects of VDRGP on bone phenotypes.

Jones, G., Nguyen, T., Sambrook, PN. & Eisman, JA.:
Thiazide diuretics and fractures: can meta-analysis help?.
J Bone Miner Res; Jan 1995, 10, 1:106-11.
Abstracts: Published observational estimates of the effect of thiazide diuretics on osteoporotic fracture risk vary
from a 70% reduction to a 60% increase but there have been no randomized controlled trials. The aims of this study
were to use the technique of meta-analysis to attempt to resolve this conflict and to explore whether duration and/or
dose of therapy has an effect on osteoporotic fracture risk. The data sources utilized were Medline and Excerpta
Medica databases supplemented by reviews and back references. A total of 18 observational studies that looked at
the relationship between diuretics and fracture were located, of which 13, involving 29,600 subjects, had extractable
data on thiazides and fracture occurrence. Current thiazide users were protected against hip fracture (OR 0.82, 95%
CI 0.73-0.91). Thiazide use of long duration may be protective (OR 0.82, 95% CI 0.62-1.08) but not short duration
(OR 1.23, 95% CI 0.99-1.54). The size of this effect, which compares favorably to other interventions, indicates that
a randomized controlled trial to resolve the problem of potential confounders and safety profile would require a
minimum of 7000 person-years of observation in those at highest risk of fracture (women aged 80 or over) which is
unlikely to be pursued at the present time. The results of this meta-analysis indicate that current thiazide users have a
20% reduction in fracture risk and that long-term use may reduce fractures by a similar amount.(ABSTRACT
TRUNCATED AT 250 WORDS).

Law, MR. & Hackshaw, AK.:
A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture:
recognition of a major effect.
BMJ 4 Oct 1997, 315, 7112: 841-46.
Abstracts: OBJECTIVE: To determine the magnitude and importance of the relation between smoking, bone mineral
density, and risk of hip fracture according to age. DESIGN: Meta-analysis of 29 published cross sectional studies
reporting the difference in bone density in 2156 smokers and 9705 non-smokers according to age, and of 19 cohort
and case-control studies recording 3889 hip fractures reporting risk in smokers relative to non-smokers. RESULTS:
In premenopausal women bone density was similar in smokers and non-smokers. Postmenopausal bone loss was
greater in current smokers than non-smokers, bone density diminishing by about an additional 2% for every 10 year
increase in age, with a difference of 6% at age 80. In current smokers relative to non-smokers the risk of hip fracture
was similar at age 50 but greater thereafter by an estimated 17% at age 60, 41% at 70, 71% at 80, and 108% at 90.
These estimates of relative risk by age, derived directly from a regression analysis of the studies of smoking and hip
fracture, were close to estimates using the difference in bone density between smokers and non-smokers and the
association between bone density and risk of hip fracture. The estimated cumulative risk of hip fracture in women in
England was 19% in smokers and 12% in non-smokers to age 85; 37% and 22% to age 90. Among all women, one
hip fracture in eight is attributable to smoking. Limited data in men suggest a similar proportionate effect of
smoking as in women. The association was not explained by smokers being thinner, younger at menopause, and
exercising less nor by actions of smoking on oestrogen, but smoking may have a direct action on bone.
CONCLUSIONS: Hip fracture in old age is a major adverse effect of smoking after the menopause. The cumulative
excess bone loss over decades is substantial, increasing the lifetime risk of hip fracture by about half.

Marshall, D., Johnell, O. & Wedel, H.:
Meta-analysis of how well measures of bone mineral
density predict occurrence of osteoporotic fractures.
BMJ 1996 312:1254-59.
Abstracts: OBJECTIVE. To determine the ability of measurements of bone density in women to predict later
fractures. DESIGN. Meta-analysis of prospective cohort studies published between 1985 and end of 1994 with a
baseline measurement of bone density in women and subsequent follow up for fractures. For comparative purposes,
we also reviewed case control studies of hip fractures published between 1990 and 1994. SUBJECTS. Eleven
separate study populations with about 90,000 person years of observation time and over 2000 fractures. MAIN
OUTCOME MEASURES. Relative risk of fracture for a decrease in bone mineral density of one standard deviation
below age adjusted mean. RESULTS. All measuring sites had similar predictive abilities (relative risk 1.5 (95%
confidence interval 1.4 to 1.6)) for decrease in bone mineral density except for measurement at spine for predicting
vertebral fractures (relative risk 2.3 (1.9 to 2.8)) and measurement at hip for hip fractures (2.6 (2.0 to 3.5)). These
results are in accordance with results of case-control studies. Predictive ability of decrease in bone mass was roughly
similar to (or, for hip or spine measurements, better than) that of a 1 SD increase in blood pressure for stroke and
better than a 1 SD increase in serum cholesterol concentration for cardiovascular disease. CONCLUSIONS.
Measurements of bone mineral density can predict fracture risk but cannot identify individuals who will have a
fracture. We do not recommend a programme of screening menopausal women for osteoporosis by measuring bone
density.

Serra-Prat M, Jovell AJ, Aymerich M.:
Eficacia y seguridad del tratamiento trombolítico en la tromboembolia pulmonar:
metaanálisis deensayos controlados y aleatorizados.
Med Clin (Barc) 1999;112;685-689.
Abstracts: Fundamento. Después de tres décadas desde la introducción de los agentes trombolíticos, su aplicación en
el tratamiento de la tromboembolia pulmonar (TEP) es aún un tema controvertido. El objetivo de este trabajo es
evaluar la eficacia y seguridad de los agentes trombolíticos en el tratamiento de la TEP mediante un metaanálisis de
ensayos controlados y aleatorizados. Métodos. Se ha realizado una búsqueda bibliográfica en las principales bases
de datos de revistas biomédicas y se han identificado 8 ensayos controlados y aleatorizados que cumplían los
criterios de selección establecidos. Dos evaluadores, de forma ciega e independiente, valoraron la calidad
metodológica de los estudios identificados según la escala validada por Jadad y extrajeron los datos necesarios para
el metaanálisis establecidos en el protocolo. Resultados. Los estudios analizados difieren en el tipo de agente
trombolítico utilizado, la pauta adoptada y las medidas del resultado principal, y presentan una puntuación mediana
de 2 puntos en la escala de Jadad. Los resultados del metaanálisis no presentan diferencias significativas en la tasa
de mortalidad y en la tasa de recurrencias entre los pacientes tratados con agentes trombolíticos y los del grupo
control. El metaanálisis muestra que los pacientes tratados con trombolíticos presentan un riesgo de hemorragia
superior a los pacientes que no recibieron este tratamiento (odds ratios [OR] = 2,62; intervalo de confianza [IC] del
95%:1,56-4,38). Conclusión. Los resultados de este metaanálisis desaconsejaron el uso sistemático de los agentes
trombolíticos en el tratamiento de la TEP en la práctica clínica habitual, ya que los riesgos parecen ser superiores a
los posibles beneficios.

Shinton, R. & Beevers, G.:
Meta-analysis of relation between cigarette smoking and stroke.
BMJ, 298(6676):789-94 1989 Mar 25.
Abstracts: There is a lack of consensus among studies on the possible risks of stroke from cigarette smoking;
because of this a meta-analysis was conducted. All published data on the association were sought and the relative
risk for each study obtained whenever possible. The pooled relative risks were calculated by using estimates of the
precision of the individual relative risks to weight their contribution to the meta-analysis. Thirty two separate studies
were analysed. The overall relative risk of stroke associated with cigarette smoking was 1.5 (95% confidence
interval 1.4 to 1.6). Considerable differences were seen in relative risks among the subtypes: cerebral infarction 1.9,
cerebral haemorrhage 0.7, and subarachnoid haemorrhage 2.9. An effect of age on the relative risk was also noted;
less than 55 years 2.9, 55-74 years 1.8, and greater than or equal to 75 years 1.1. A dose response between the
number of cigarettes smoked and relative risk was noted, and there was a small increased risk in women compared
with men. Ex-smokers under the age of 75 seemed to retain an appreciably increased risk of stroke (1.5); for all ages
the relative risk in ex-smokers was 1.2. The meta-analysis provides strong evidence of an excess risk of stroke
among cigarette smokers. Stroke should therefore be added to the list of diseases related to smoking.

Wolff, I., van Croonenborg, JJ., Kemper, HC., Kostense, PJ. & Twisk, JW.:
The effect of exercise training programs on bone mass:
a meta-analysis of published controlled trials in pre- and postmenopausal women.
Osteoporos Int. 1999, 9, 1: 1-12.
Abstracts: With the aging of the population, the medical and social costs of skeletal fragility leading to fractures will
cause an immense burden on society unlesseffective prophylactic and therapeutic regimens can be developed.
Exercise is suggested as a possible regimen against involutional bone loss. The purpose of thepresent meta-analysis
is to address a quantitative review of the randomized controlled trials (RCTs) and nonrandomized controlled trials
(CTs) on the effects ofexercise training programs on bone mass, measured as bone mineral density (BMD) or bone
mineral content (BMC), of the lumbar spine (LS) and the femoral neck(FN) in pre- and postmenopausal women.
The literature from 1966 through December 1996 was searched for published RCTs and CTs. Study treatment effect
isdefined as the difference between percentage change in bone mass per year in the training group and the control
group. Overall treatment effects (OTs) with the 95%confidence intervals of these study treatment effects were
calculated using inverse-variance weighting. Of the 62 articles identified, 25 met the inclusion criteria andwere
maintained for further analyses. The weighted OTs for the RCTs showed very consistently that the exercise training
programs prevented or reversed almost 1%of bone loss per year in both LS and FN for both pre- and
postmenopausal women. The two OTs that could be calculated for strength training programs did notreach
significance. The OTs for the CTs were almost twice as high as those for the RCTs, which gives an indication of the
confounding introduced by the nonrandomallocation of the subjects to groups.

Zhang, WY. & Li-Wan-Po, A.:
Analgesic efficacy of paracetamol and its combination with codeine and
caffeine in surgical pain: a meta-analysis.
J Clin Pharm Ther. 1996 Aug; 21, 4: 261-82.
Abstracts: The objective of this study was to quantify the analgesic efficacy of paracetamol and its combination with
codeine or caffeine through a systematic overview and meta-analysis of relevant randomized controlled trials
(RCTs). Systematic retrieval of relevant clinical trials was carried out using computerized searches, historical
searches and communication with manufacturers. The results of RCTs were pooled to estimate (i) the difference in
percentage improvement of total pain relief (TOTPAR%) and the sum of pain intensity difference (SPID%); (ii) the
proportions of patients obtaining moderate to excellent pain relief relative to placebo (ResRR) and (iii) the ratio of
patients requiring analgesic re-medication (RemRR). Head-to-head comparisons were also undertaken for
paracetamol versus its combination with codeine or caffeine. A total of 80 RCT reports describing 103 placebo
comparisons and 26 head-to-head comparisons were identified. The total pain relief score in the single dose studies
increased by 38 percentage points for paracetamol and by 24 points for placebo. The difference (d) in TOTPAR%
between the two was highly significant (d = 14, 95% CI: 12, 16). For the difference in SPID%, d = 12, 95% CI: 11,
13. Patients were more than twice as likely to obtain moderate to excellent pain relief on paracetamol than on
placebo (ResRR = 2.39, 95% CI: 1.89, 3.02), and less likely to require re-medication (RemRR = 0.78, 95%
CI: 0.69, 0.88). There was no significant (P > 0.05) dose-response relationship. The analgesic efficacy of paracetamol
600 mg was enhanced with the addition of codeine 60 mg (using TOTPAR% as outcome) in both indirect and head-to-head
comparisons. SPID%, but not ResRR and RemRR, data supported this conclusion. Much weaker effects were observed
with the caffeine combination. Adverse effects were mild. Surprisingly, drowsiness was seen more often with paracetamol
and paracetamol-codeine combinations than with placebo. The relative risks (95% CI) were 1.83 (1.29, 2.59) and 2.39
(1.58, 3.57), respectively. In conclusion paracetamol is an effective analgesic for post-surgical pain. Caffeine adds little to
the analgesic effect of paracetamol. However, there is some evidence that codeine 60 mg adds to the analgesic effects of
paracetamol 600 mg, using pain relief or pain intensity scores as outcomes, but this is not necessarily translated into an
increase in number of patients who obtain moderate to excellent pain relief.

Baron, JA., Karagas, M., Barrett, J., Kniffin, W., Malenka, D., Mayor, M. & Keller, RB.:
Basic epidemiology of fractures of the upper and lower limb among Americans over 65
years of age.
Epidemiology, 7 (6): 612-8, Nov 1996.
Abstract: Current knowledge regarding the basic epidemiology of fractures is largely limited to a few fracture sites,
notably those of the hip and distal forearm. Toclarify the patterns of incidence of limb fractures in the elderly, we
used data from a 5% sample of the U.S. Medicare population over age 65 years during the years1986-1990. We
identified incident fractures of the proximal humerus, other parts of the humerus, proximal radius/ulna, shaft of the
radius/ulna, distal radius/ulna,pelvis, hip, other parts of the femur, patella, ankle, and other parts of the tibia/fibula
from diagnoses and procedures coded on claims for inpatient services, outpatientfacility use, and physician services.
We used Poisson regression to investigate the relation between demographic factors and fracture risk at these sites.
Fractures atthe hip were the most common, accounting for 38% of the fractures identified. The proximal humerus,
distal radius/ulna, and ankle also were common fracture sites.A pattern of rapidly rising rates with age was seen for
fractures of the pelvis, hip, and other parts of the femur among women. Fractures distal to the elbow or
knee,however, had, at most, modest increases in incidence with age over 65 years. For each of the fractures studied,
women had higher rates than men of the same race,and whites generally had higher rates than blacks of the same
gender. Gender-related differences in risk were larger among whites than among blacks, and racialdifferences in risk
were more marked among women than among men.
 

[Cintura escapular]
 

Phillips, AM., Smart, C. & Groom, AF.:
Acromioclavicular dislocation.
Clin Orthop. 1998 Aug, 353: 10-7.
Abstracts: A literature review was performed to clarify available information which influences decisions whether to
advise a young adult patient to undergo surgery for a severely displaced acromioclavicular dislocation. Twenty-four
papers were retrieved yielding 1172 patients of whom the mean followup for the 833 surgically treated patients was
43.7 months and not surgically treated was 60.4 months. Of the 24 papers, only five reported surgical and
conservative outcomes; two of these papers used prospective randomized methodology and three used
nonrandomized methodology. Fourteen papers reported surgical outcome only and five papers reported conservative
outcome only. Overall, 88% of surgically treated patients and 87% of nonsurgically treated patients had a
satisfactory outcome. Complications most commonly listed were (surgically treated versus nonsurgically treated):
need for further surgery (59% versus 6%), infection (6% versus 1%), and deformity (3% versus 37%). Return to
activity was no quicker with surgery. Pain was not any more common without surgery. Range of movement was
more frequently normal or near normal without surgery (95% versus 86% if surgically treated) and so was strength
(92% versus 87%). Meta-analysis of the four studies including data from surgical and conservative therapy showed
on significant benefit from surgery. Power studies suggest that to show a statistically significant benefit from
surgery, large studies would be required, which, given the relative incidence of these injuries, would probably be
multicenter and therefore vulnerablto methodologic difficulties. There does not seem to be any reason to recommend
an operative procedure to a patient with a Rockwood et al Type III injury based on the evidence currently available.

Bannister, GC., Wallace, WA., Stableforth, PG. & Hutson, MA.:
A classification of acute acromioclavicular dislocation:
a clinical, radiological and anatomical study.
Injury 1992, 23, 3:194-6.
Abstracts: Forty-eight patients with acute acromioclavicular dislocation were assessed clinically and radiologically
before random allocation to non-operative management (28) or open reduction and coracoclavicular screw fixation
(20) and followed for a minimum of 4 years. In 6 patients, late salvage surgery was required, the results of which
were inferior to early operative intervention. Early surgery also gave better results than non-operative treatment in
severe disruptions which could be identified in the acute stage. Three types of acromioclavicular dislocation which
have predictable clinical outcomes could be distinguished on radiographs. When treated non-operatively, type A
dislocations (19 per cent) may develop painful subluxation, type B (68 per cent) remain dislocated but retain
sufficient muscle attachment to avoid fatigue on activity, and type C (12 per cent) leave a weak and unsightly
shoulder. In type C dislocations, the clavicle is displaced 2 cm or more from the acromion on plain anteroposterior
radiographs and the attached origin of the anterior deltoid is avulsed. Type C dislocations may benefit from early
operative reconstruction.

Eskola, A., Vainionpaa, S., Korkala, O. & Rokkanen, P.:
Acute complete acromioclavicular dislocation.
A prospective randomized trial of fixation with smooth or threaded Kirschner
wires or cortical screw.
Ann Chir Gynaecol 1987, 76, 6:323-6.
Abstracts: During 1983-1984, 86 patients with complete dislocation of the acromioclavicular joint verified also by
stress radiographs were operated on and followed-up for at least one year. In transfixation two smooth Kirschner
wires, two threaded Kirschner wires or one cortical screw were used. The acromioclavicular ligament was sutured
and the damaged disk removed, but the coracoclavicular ligament was left unsutured. At the one-year follow-up, the
results were good in 82 patients according to the classification of Darrow et al. Radiologically, the
acromioclavicular joint was in place in 67 patients. Partial dislocation was observed in 14 patients and complete
dislocation in 5 patients. Clinical results were not related to the type of treatment. The only statistically significant
difference was osteolysis of the lateral head of the clavicle; eight of the 13 cases of osteolysis were due to screw
fixation (p less than 0.001).

Jensen, PO., Andersen, K. & Lauritzen, J.:
Treatment of mid-clavicular fractures.
A prospective randomized trial comparing treatment with figure-of-eight dressing and
simple arm sling.
Ugeskr Laeg 1985, 147, 25:1986-1988.
Abstracts: During a two-year period, 100 outpatients were treated for mid- clavicular fractures in a prospective
randomized trial with the purpose of comparing the results of figure-of-eight bandage with a simple sling. Thirtynine
patients were excluded because they did not wish to participate, complications or failures in registration.
Thirty-four patients were treated with figure-of-eight bandage and 27 with a simple arm sling. After a follow-up
period of three months, all patients were evaluated clinically and radiologically. No cases of non-union occurred.
Concerning the period of treatment, the simple sling was superior to the figure-of-eight dressing because of fewer
complications. It was less uncomfortable and demanded fewer resources. No differences were observed after three
months regarding the functional and cosmetic end-results.

Kock, HJ., Jurgens, C., Hirche, H., Hanke, J. & Schmit-Neuerburg, KP.:
Standardized ultrasound examination for evaluation of instability of the acromioclavicular joint.
Arch Orthop Trauma Surg 1996, 115, 3-4:136-40.
Abstracts: Anteroposterior X-ray views of both acromioclavicular (AC) joints with 10-kg weights held in each hand
are the generally accepted procedure for diagnosis of Tossy I-III grades of AC joint separation. An analogous
diagnosis can be made by standardized ultrasound examination. Ten individuals with Tossy-I, 11 with Tossy-II and
8 with Tossy-III instability were examined both radiographically and by B-mode ultrasound. The degree of AC joint
separation was uniformly determined on the basis of a calculated index (AC Index = AC joint width of uninjured
side/AC joint width of injured side). The mean AC Index for Tossy-I instability determined by ultrasound was 1.0;
mean indices of 0.49 and 0.5 were determined for Tossy-II injury by ultrasound and X-ray, respectively, and of 0.21
and 0.2, respectively, for Tossy-III instability. Statistical analysis showed significant differences between the mean
AC indices of all three groups (P < 0.0001). We conclude that the reliability of ultrasound examination of AC joint
instability is equal to that of radiographic measurement. Standard X-rays of the shoulder remain mandatory only to
exclude fracture. The indication for operative stabilization of the AC joint can be established on the basis of the
grade of AC joint instability measured by the side-effect-free and cost-effective method of ultrasound examination
(AC Index < 0.3 equivalent to Tossy-III instability).

Larsen, E., Bjerg-Nielsen, A. & Christensen, P.:
Conservative or surgical treatment of acromioclavicular
dislocation. A prospective, controlled, randomized study.
J Bone Joint Surg. 1986, 68-A, 4:552-5.
Abstracts: In a prospective, controlled, randomized study of acute acromioclavicular dislocations, we compared
conservative and operative treatment (the Phemister procedure) with regard to the clinical results, complications,
and social costs. Forty-one patients were operated on and forty-three patients were treated conservatively. Two
patients who were operated on and three who were treated conservatively had to have the lateral extremity of the
clavicle resected because of pain. The rehabilitation period was significantly shorter with non-operative treatment,
and after thirteen months there was no difference in the clinical results. There were no serious postoperative
complications, but about half of the patients who were operated on had problems with the metallic device, such as
breakage or migration of the pins, or both, and six patients had a superficial infection. For most patients with total
acromioclavicular dislocation we recommend conservative treatment with a sling until the patient is free of pain.
Operation should be considered in thin patients who have a prominent lateral end of the clavicle, in those who do
heavy work, and in patients whose daily work requires that the shoulder often be held in about 90 degrees of
abduction and flexion.
 

[Hombro]
 

Beattie, TF., Steedman, DJ., McGowan, A; Robertson, CE.:
A comparison of the Milch and Kocher techniques for acute anterior dislocation of the
shoulder.
Injury 1986, 17, 5:349-52.
Abstracts: Two methods of reduction for anterior dislocation of the shoulder were compared in 111 patients. Milch's
technique was found to be atraumatic and relatively painless. Greater success with Milch's technique was
experienced in patients under 40 years of age in whom the dislocation had been present for less than 4 hours. Milch's
technique should be tried initially in patients fulfilling these criteria. In other cases Kocher's technique should be
used first, especially in those of heavy build.

Brox, JI., Staff, PH., Ljunggren, AE. & Brevik, JI.:
Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease
(stage II impingement syndrome) [published erratum appears in BMJ 1993 Nov 13;307 (6914):
 1269] [see comments].
BMJ 1993, 307, 6909:899-903.
Abstracts: The effectiveness of arthroscopic surgery, supervised exercises, and placebo was compared in 125
patients with rotator cuff disease (impingement syndrome stage II) in a randomized clinical trial. The median age
was 48 years, and the median duration of complications was 1 to 2 years. The treatments were arthroscopic
subacromial decompression performed by 2 experienced surgeons, an exercise regimen supervised for 3 to 6 months
by 1 experienced physiotherapist, or 12 sessions of detuned soft laser (placebo) for 6 weeks. The criterion for
success was a Neer shoulder score > 80. Fifteen (50%) and 11 (22%) of the patients randomized to placebo and
exercises, respectively, had surgery during the 2 1/2-year follow-up period and were classified as having failure with
the treatments. The success rate was higher (P < .01) for patients randomized to surgery (26 of 38) and exercises (27
of 44) compared with the placebo group (7 of 28). The odds ratio for success after surgery compared with exercises
was 1.5 (95% confidence interval 0.6 to 3.7; P = .49). Including all patients who underwent operation, the success
rate in those not on sick leave (19 of 21) before surgery was higher compared with those on sick leave (18 of 36)
(adjusted odds ratio 5.6 [1.2 to 29.2]). Similar results were observed for patients not receiving versus those receiving
regular pain medication before surgery (adjusted odds ratio 4.2 [1.2 to 15.8]).

Gleeson, AP., Graham, CA., Jones, I., Beggs, I. & Nutton, RW.:
Comparison of intra-articular lignocaine and a suprascapular nerve block for acute anterior
shoulder dislocation.
Injury 1997, 28: 141-142.
Abstracts: We compared the analgesic effects of a suprascapular nerve block with intra-articular local anaesthetic in
20 patients presenting with acute anterior glenohumeral dislocations. The intra-articular local anaesthetic technique
was a simpler procedure which provided significantly more analgesia for patients.

Suder, PA., Mikkelsen, JB., Hougaard, K. & Jensen, PE.:
Reduction of traumatic primary anterior shoulder
dislocations with local anaesthesia
[Reponering af traumatisk primaer anterior skulderluksation i lokal analgesi].
Ugeskrift-for-Laeger 1995, 157: 3625-3629.
Abstracts: The aim of the present study was to evaluate the value of local versus intravenous anaesthesia in the
reduction of acute shoulder dislocations. Patients with a primary traumatic dislocation of the shoulder were
randomized to either local lidocaine or intravenous anaesthesia with pethidine/diazepam. The local method was
performed with 20 ml of 1% lidocaine. The intravenous method was performed with pethidine/diazepam injected
intravenously. The patients were observed for any complication during and after the procedure and the used methods
were evaluated using a Visual Analogue Scale (VAS). In the period from November 1991 to September 1993 81
patients were admitted to our departments and 68 patients were included. Average age was 48 years (range 15-79)
with 29 men and 39 women. Thirty-five patients were randomized to intravenous anaesthesia, 33 had a successful
reduction and two failed. Thirty-three patients received local anaesthesia, 32 succeeded and one failed. Ten patients
treated with the intravenous method had respiratory depression and six required antidote. No systemic or local side
effects and no neuro-vascular injuries were recorded with the use of lidocaine. We did not observe any superficial or
deep infection in the lidocaine group. There was no statistical difference between the average VAS value in the two
groups. Local anaesthesia used to reduce acute primary anterior dislocation of the shoulder is a simple, safe and
well-accepted method with significantly fewer respiratory.

Vecchio, PC. Hazleman, BL. & King, RH.:
A double-blind trial comparing subacromial methylprednisolone
and lignocaine in acute rotator cufftendinitis.
Br J Rheumatol 1993, 32, 8:743-5.
Abstracts: Fifty-five patients with shoulder pain due to rotator cuff tendinitis of less than 12 weeks' duration were
randomized to receive either 40 mg methylprednisolone and lignocaine or lignocaine alone. No statistically
significant difference could be discerned between the two groups during 12 weeks of follow-up.

Watson, M.:
Major ruptures of the rotator cuff. The results of surgical repair in 89 patients.
J Bone Joint Surg 1985, 67-B, 4:618-24.
Abstracts: Major ruptures of the rotator cuff were repaired in 89 patients over a six-year period, using an approach
through the split deltoid muscle and the bed of the excised outer centimetre of the clavicle. Review of these patients
showed that poor results were associated with larger cuff defects, with more pre-operative steroid injections and
with pre-operative weakness of the deltoid muscle. A randomised prospective study showed that repair followed by
splinting in abduction gave no better results than repair followed by resting the arm at the side. Excision of the
coraco-acromial ligament was associated with worse results than leaving its divided halves in situ. Follow-up
showed that the results continued to improve for two years after operation; their quality was maintained in patients
less than 60 years old, but in those over 60 there was deterioration with time.
 

[Brazo]
 
 

Farragos, AF., Schemitsch, EH. & McKee, MD.:
Complications of intramedullary nailing for fractures of the
humeral shaft: a review.
J Orthop Trauma. 1999 May, 13, 4: 258-67.
Abstracts: Objectives: The purpose of the present review is to document the complications associated with the use of
locking humeral nails and to discuss the prevention and management of these complications. Data sources: Clinical
and research experience supported by a Medline review of the English-language literature from 1985 to 1998. Study
selection: The majority of (clinical) information available was contained in retrospective reviews; only three
prospective or randomized studies were identified (all in abstract form). Anatomical research regarding locking
humeral nailing was also identified and included. Data extraction: Because there were so few prospective studies
available, a formal meta-analysis of data was not performed. This review focuses on a descriptive assessment of
available information on specific complication-related topics. Conclusions: The attractive theoretical advantages of
locking humeral nails have not been borne out in clinical studies. Complications such as shoulder pain, delayed
union or nonunion, fracture about the implant, iatrogenic fracture comminution, and the difficulty in the
reconstruction of failures have diminished their usefulness. The precise role of locking nails in the treatment of
humeral shaft fractures has yet to be defined. At present, open reduction and compression plating remain the
treatment of choice for humeral shaft fractures that require operative intervention.

Chiu, FY.; Chen, CM.; Lin, CF.; Lo, WH,; Huang, YL. & Chen, TH.:
Closed humeral shaft fractures: a prospective evaluation of surgical treatment.
J Trauma 1997, 43:947-51. Comment in: J Trauma Jun 1998, 44, 6:1115.
Abstracts: Objective: We tried to define the roles of the rigid dynamic compression plate (DCP) and the semi-rigid
Ender nail (EN) in the treatment of closed humeral shaft fractures.Design: A prospective, randomized clinical study
was performed with detailed comparison parameters. Materials and Methods: Ninety-one closed humeral shaft
fractures were treated. Randomly, 30 humeri were treated with open reduction and internal fixation with DCP and
no bone grafting (BG), 29 were treated with the same procedure but with BG, and 32 were treated with closed
reduction and internal fixation with Ender nails. The average follow-up period was 32 months (range, 13-54
months).Measurements and Main Results: In the group with DCP without BG, the average blood loss was 270 ml,
operation time was 92 minutes, hospital length of stay was 6.5 days, and union time was 12.5 weeks. In the group
with DCP with BG, the average blood loss was 325 mL, operation time was 108 minutes, hospital length of stay was
6.9 days, and union time was 9.4 weeks. In the EN group, the average blood loss was 114 mL, operation time was
54 minutes, hospital length of stay was 5.6 days, and union time was 9.9 weeks. Analysis of variance and Fisher's
exact test were used to evaluate the statistical significance.Conclusion: In our experience, for humeral shaft fractures
fixed surgically, EN is better than DCP without BG. When DCP is chosen for the means of fixation, prophylactic
BG is recommended, especially in cases with more comminution.Key Words: Dynamic compression plate, Ender
nail, Humeral shaft fracture.

Rodriguez-Merchan, EC.:
Compression plating versus hackethal nailing in closed humeral shaft fractures
failing nonoperative reduction.
J.Orthop.Trauma.; 9: 194-197, 1995. Comment in: J Orthop Trauma 1995, 9, 6:533-4.
Abstracts: Prospectively, 40 patients with an average age of 45 (20-65) with closed transverse fractures of the
middle one-third of the humerus without associated radial nerve palsy were treated. All had failed nonoperative
reduction and were then operated on with either compression plating or intramedullary fixation with Hackethal nails
and a postoperative ready-made fracture brace. These surgeries were performed at an average of 7 days (4-10) after
closed reduction. The Hackethal nailing group consisted of 20 patients (17 men, 3 women) with a mean age of 47
years (22-64); within 2 days after surgery the patients were allowed to begin active and passive range-of-motion
exercises of the elbow and the shoulder with the arm protected by a ready-made fracture brace; the average followup
period for this group was 18 months (12-50). These patients (with one exception) required a second surgical
procedure with a second anesthesia to remove the symptomatic nails; moreover, they had to be protected in a brace
for 6 months. The compression plate group consisted of 20 patients (14 men, 6 women) with a mean age of 45 years
(20-65); within 2 days after surgery the patient was allowed to begin the same rehabilitation program; in this group
no braces were used postoperatively. All fractures treated with Hackethal nailing healed except for one delayed
union. Functional results in this group were 12 excellent, 4 good, 1 fair, and 3 poor. All fractures treated by
compression plating healed except in one case of delayed union.

Blum, J., Rommens, PM. & Janzing, H.:
The unreamed humeral nail: a biological osteosynthesis of the upper arm.
Acta Chir Belg 1997, 97, 4: 184-9.
Abstracts: One hundred humeral shaft fractures have been treated by closed retrograde locked intramedullary
nailing. The Russell-Taylor nail was used in 58, a Synthes prototype of an unreamed humeral nail in 42 cases.
Excellent shoulder function after consolidation has been found in 90%, excellent elbow joint function in 86%.
Among four cases of postoperative radial nerve palsy, three fully recovered within three months and one patient
needed a secondary exploration. In three cases additional comminution at the fracture site occurred. Interlocking bolt
breakage has been seen in three, slight nail migration with no adverse consequences in two cases, an additional
supracondylar fracture in one case. Nine patients needed a secondary internal fixation because of disturbed fracture
healing. Compared to complication rates and end results in shoulder and elbow function of plate fixation or
anterograde nailing in the treatment of humeral shaft fractures, the retrograde locked humeral nail seems to present
itself as the better implant for these fracture types. The number of radial nerve palsies is significantly lower than in
plate osteosynthesis. A huge advantage compared to plate osteosynthesis is also the biological type of stabilization
with minimal invasion of the soft tissues. There is also minimal damage to periosteal and endosteal blood supply.

Nast-Kolb, D.; Knoefel, WT. & Schweiberer, L.:
The treatment of humeral shaft fractures. Results of a prospective AO multicenter study
[Die Behandlung der Oberarmschaftfraktur. Ergebnisse einer
prospektiven AO-Sammelstudie] .
Unfallchirurg 1991, 94:447-54.
Abstracts: This prospective multicenter study conducted by the German section of the AO International analyzes
302 fractures of the humeral shaft, 170 (56%) of which were operated upon and 132 (44%), treated conservatively.
Among those operated upon, 3.5% developed infections and 10% showed paresis of the radial nerve. In contrast, the
only complication in the group treated conservatively was pseudarthrosis, in 1 case. However, further analysis
revealed that complications were distributed unequally among the centers and the most complications were reported
from only a few hospitals. We were able to contact 173 (57%) patients for follow-up. Results of operative and
conservative treatment were compared for similar fractures. Both techniques resulted in predominantly good to
excellent results. The somewhat inferior results in the group operated upon were explained by the higher percentage
of associated local injuries and concomitant injuries to other organs. The results of this study were compared with
those of other recent studies, and recommendations were established for the operative and conservative treatment of
fractures of the humeral shaft.

Tytherleigh-Strong, G., Walls, N. & McQueen, MM.:
The epidemiology of humeral shaft fractures.
J Bone Joint Surg March 1998, 80-B, 2:249-253.
Abstracts: We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The
fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of
injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the
Tscherne system. The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most
(60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The
severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the
fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to
severe injury in men and a larger peak in the seventh decade after a simple fall in women.
 

[Codo]
 
 

Evans, MC. & Graham, HK.:
Radial neck fractures in children: a management algorithm.
J Pediatr Orthop B. 1999 Apr, 8, 2: 93-9.
Abstracts: Fractures of the radial neck in children are relatively rare. The outcome is dependent not only on the
injury but also on the method of treatment and the presence of any associated injury. During the past 20 years, two
new minimally invasive reduction techniques have been described in an attempt to improve the prognosis, and their
results have been reported. A meta-analysis of the recent literature with the focus on outcome, and a management
algorithm for this rare fracture are presented.

Labelle, H., Guibert, R. & Joncas, J.:
Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow:
An attempted meta-analysis.
J Bone Joint Surg 1992, 74-B:646-51.
Abstracts: We have reviewed 185 articles published since 1966 to assess the scientific evidence for methods of
treatment for lateral epicondylitis of the elbow. Of the 185 articles, 78 discussed treatment, but since the natural
history of the syndrome is uncertain we considered only those series with concurrent control groups. Only 18 of
these were randomised and controlled studies. We then graded these papers for scientific validity, using the methods
of Chalmers et al (1981). The mean score of the 18 articles was only 33%, with a range from 6% to 73%. A
minimum of 70% is required for a valid clinical trial, and we therefore concluded that there was insufficient
scientific evidence to support any of the current methods of treatment. There were too many methodological
differences to allow a quantitative meta-analysis, but our qualitative review established the importance of the natural
evolution of the syndrome and of the placebo effect of all treatments. Properly designed, controlled trials are needed.

Geutjens, GG., Langstaff, RJ., Smith, NJ., Jefferson, D., Howell, CJ. & Barton, NJ.:
Medial epicondylectomy or ulnar-nerve transposition for ulnar neuropathy at the elbow?
J Bone Joint Surg Br, 78(5):777-9 1996 Sep.
Abstracts: We carried out a prospective randomised study comparing medial epicondylectomy with anterior
transposition for the treatment of ulnar neuropathy at the elbow. The mean follow-up period was 4.5 years and we
assessed the patients neurologically and orthopaedically. Neither procedure appeared to have a significant effect on
elbow function. Our study showed better results after medial epicondylectomy; in particular patient satisfaction was
higher than after ulnar nerve transposition. There were no significant differences in motor power or nerveconduction
rates and sensory fibres appeared to be more vulnerable to devascularisation.

Henriksen, BM., Gehrchen, PM., Jorgensen, MB. & Gerner-Smidt, H.:
Treatment of traumatic effusion in the elbow joint: a prospective, randomized study of 62
consecutive patients.
Injury 1995, 26, 7:475-8.
Abstracts: Sixty-two patients with post-traumatic radiologically visualized effusion in the elbow joint, apparently
without bony damage, were randomized to either 1 week of immobilization in a plaster or immediately instructed in
active exercises without any immobilization. They were reexamined by an orthopaedic surgeon weekly until
recovery. New radiographs were taken after 1 week. Reevaluation of the radiographs by a radiologist revealed seven
'false-positive' effusions, i.e. neither effusion nor fracture, and 21 missed fractures. All but five missed fractures,
continued in the study. Thirty patients started immediate active exercises instructed by the surgeon and 27 were
immobilized. The 'active exercise' group had a significantly shorter recovery time (one week vs two weeks, P <
0.05). The presence of missed fractures did not influence the result and all patients recovered fully. Also four of the
excluded patients with missed fractures recovered fully. One patient with missed fracture dropped out from followup.
We recommend that an apparently isolated post-traumatic effusion in the elbow joint is treated with immediate
active exercises followed by a clinical reexamination after one week supplemented with new radiographs if there is
unsatisfactory clinical progress.

Holdsworth, BJ. Clement, DA. & Rothwell, PN.:
Fractures of the radial head, the benefit of aspiration:
a prospective controlled trial.
Injury 1987, 18, 1:44-7.
Abstracts: The clinical progress of 80 adults with fractures of the radial head was followed prospectively. Early
active movement of the elbow and forearm was encouraged in all patients. Better functional results were achieved
by the study group than by retrospective controls in whom active movement was delayed. Aspiration of the elbow
and instillation of local anaesthetic were carried out in a randomly selected half of the patients. This afforded relief
of pain in 92 per cent and made early movement more comfortable. The fracture was more common in women.
Functional recovery was best in younger patients and was closely related to the severity of the fracture.

Hume, MC. & Wiss, DA.:
Olecranon fractures. A clinical and radiographic comparison of tension band
wiring and plate fixation.
Clin Orthop. 1992, 285:229-35.
Abstracts: Forty-one adult patients with displaced olecranon fractures were treated with open reduction internal
fixation in a prospective, randomized study comparing tension band wiring (TBW) and plate fixation (PF). Plate
fixation required longer operative time, but did not lead to an increased complication rate. Range of elbow motion at
six months did not differ significantly between the two groups. Symptomatic metal prominence was frequently
observed after TBW (42%), although true Kirschner wire (K-wire) migration was seen in only one patient.
Postoperative loss of reduction, leading to a significant articular step-off or gap, was more frequent after TBW
(53%) than after PF (5%). Tension band wiring resulted in 37% good clinical and 47% good roentgenographic
results, as compared with PF, which resulted in 63% good clinical and 86% good roentgenographic results. Plate
fixation should be carefully considered when planning open reduction and internal fixation of displaced olecranon
fractures.

Macias, CG., Bothner, J. & Wiebe, R:
A comparison of supination/flexion to hyperpronation in the reduction
of radial head subluxations.
Pediatrics 1998, 102, 1:10.
Abstracts: OBJECTIVE: To compare supination at the wrist followed by flexion at the elbow (the traditional
reduction technique) to hyperpronation at the wrist in the reduction of radial head subluxations (nursemaid's elbow).
MATERIALS AND METHODS: This prospective, randomized study involved a consecutive sampling of children
younger than 6 years of age who presented to one of two urban pediatric emergency departments and two suburban
pediatric ambulatory care centers with a clinical diagnosis of radial head subluxation. Patients were randomized to
undergo reduction by one of the two methods and were followed every 5 minutes for return of elbow function. The
initial procedure was repeated if baseline functioning did not return 15 minutes after the initial reduction attempt.
Failure of that technique 30 minutes after the initial reduction attempt resulted in a cross-over to the alternate
method of reduction. The alternate procedure was repeated if baseline functioning did not return 15 minutes after the
alternate procedure was attempted. If the patient failed both techniques, radiography of the elbow was performed.
RESULTS: A total of 90 patients were enrolled in the study. Five patients were removed from further analysis
secondary to a final diagnosis of fracture, 84 were reduced successfully, and 1 failed both techniques. Demographic
characteristics of each group were similar. Thirty-nine of 41 patients (95%) randomized to hyper-pronation were
reduced successfully on the first attempt versus 34 of 44 patients (77%) randomized to supination. Two patients in
the hyperpronation group required two attempts versus 10 patients in the supination group. Hyperpronation was
more successful; 40 of 41 patients (97.5%) in the hyperpronation group were reduced successfully versus 38 of 44
patients (86%) in the supination group. Of the 6 patients who crossed over from supination to hyperpronation, 5
were reduced on the first attempt and 1 was reduced on the second attempt. CONCLUSIONS: In the reduction of
radial head subluxations, the hyperpronation technique required fewer attempts at reduction compared with
supination, was successful more often than supination, and was often successful when supination failed.

Poynton, AR., Kelly, IP. & O´Rourke, SK.:
Fractures of the capitellum: a comparison of two fixation methods.
Injury 1998, 29, 5:341-43.
Abstracts: Isolated capitellar fractures are rare, accounting for only 1 per cent of all elbow fractures (Bryan and
Morrey, The Elbow and its Disorders, 1985). Many different fixation methods have been described but no series has
compared these treatment modalities because of the rarity of these fractures. This paper compares the outcome of
two types of fixation of type I capitellar fractures. Group one (n = 6) had open reduction and Kirschner wire fixation
while group two (n = 6) had open reduction and Herbert screw fixation. Both groups were compared clinically,
functionally and radiographically. We found that Herbert screw fixation enabled earlier mobilization and a better
functional outcome.

Rompe, JD., Hope, C., Kullmer, K., Heine, J. & Burger, R.:
Analgesic effect of extracorporeal shock-wave
therapy on chronic tennis elbow.
J Bone Joint Surg Br, 78(2):233-7 1996 Mar.
Abstracts: We report a controlled, prospective study to investigate the effect of treatment by low-energy
extracorporeal shock waves on pain in tennis elbow. We assigned at random 100 patients who had had symptoms for more than 12 months to two groups to receive low-energy shock-wave therapy. Group I received a total of 3000
impulses of 0.08 mJ/mm2 and group II, the control group, 30 impulses. The patients were reviewed after 3, 6 and 24
weeks. There was significant alleviation of pain and improvement of function after treatment in group I in which
there was a good or excellent outcome in 48% and an acceptable result in 42% at the final review, compared with
6% and 24%, respectively, in group II.
 

[Antebrazo]
 
 

Atkin, DM., Bohay, DR., Slabaugh,P. & Smith, BW.:
Treatment of ulnar shaft fractures: a prospective, randomized study.
Orthopedics 1995, 18, 6:543-7. [Abstract]
Abstracts: The treatment of isolated ulnar shaft fractures is controversial. Previous studies comparing treatment
options have been largely retrospective and nonrandomized. In this study, consecutive patients were randomized
into treatment groups of long arm plaster immobilization, short arm plaster immobilization, or Ace Wrap bandage,
based on the order of hospital admission. Thirty-one patients were followed until radiographic or clinical union, with
no significant difference in time to union between groups. Age, sex, fracture pattern, and displacement did not
significantly influence time to union or final angulation. Two patients in both the long arm cast group and the short
arm cast group lost significant motion at final follow up. Seventy percent of patients in the Ace Wrap group failed
treatment secondary to pain and were converted to plaster immobilization. Furthermore, patients in this group
demonstrated significantly greater angulation than those treated in a long arm cast. Our results demonstrate that
above-elbow plaster immobilization offers no advantage over below-elbow immobilization. We recommend short
arm casting for a period of 8 weeks.
 

[Muñeca y mano]
 
 

Hansen, PB., & Hansen, TB.:
The treatment of fractures of the ring and little metacarpal necks.
A prospective randomized study of three different types of treatment.
J Hand Surg Br 1998, 23, 2:245-47.
Abstracts: A total of 105 patients with fracture of the neck of the ring or little metacarpal bone were randomized to
receive three different types of treatment: dorso-ulnar plaster-of-Paris from the proximal interphalangeal joint to
elbow; functional brace around the wrist; or elastic bandage. Twenty patients (19%) had to be excluded for different
reasons leaving 85 patients in the study. The remaining patients were examined after 4 weeks and 3 months. There
was no difference in patient satisfaction between the three different types of treatment. The functional brace was in
our opinion superior to the two other types of treatment: the patients had as little pain as the patients treated with
plaster-of-Paris and less pain than patients treated with elastic bandage. Patients treated with a functional brace
mobilized as fast as patients treated with elastic bandage and faster than patients treated with plaster-of-Paris. Based
on these findings, we recommend the functional brace for treatment of fractures of the neck of the ring and little
metacarpals.

Jensen, CH., & Jensen, CM.:
Biodegradable pins versus Kirschner wires in hand surgery.
J Hand Surg Br 1996, 21, 4:507-10.
Abstracts: We compared biodegradable pins with standard Kirschner wires in the fixation of fractures, arthrodeses
and osteotomies in the hand in a prospective, randomized study. Eleven patients were allocated to the biodegradable
pin group and 12 to the Kirschner wire group. Age, gender, operative procedure and postoperative treatment did not
differ in the two groups. All patients were evaluated after 6 months. No differences in time to union or complication
rates were found, but the number of additional operative procedures in the Kirschner wire group significantly
exceeded the number needed in the biodegradable pin group.

Kristiansen, TK., Ryaby, JP., McCabe, J., Frey, JJ. & Roe, LR.:
Accelerated healing of distal radial fractures with the use of specific, low-intensity ultrasound.
A multicenter, prospective, randomized, double-blind, placebo-controlled study.
J Bone Joint Surg Am, 79(7):961-73 1997 Jul.
Abstracts: A multicenter, prospective, randomized, double-blind, placebo-controlled clinical trial was conducted to
test the efficacy of a specifically programmed, low-intensity, non-thermal, pulsed ultrasound medical device for
shortening the time to radiographic healing of dorsally angulated fractures (negative volar angulation) of the distal
aspect of the radius that had been treated with manipulation and a cast. Sixty patients (sixty-one fractures) were
enrolled in the study within seven days after the fracture. The patients used either an active ultrasound device (thirty
fractures) or a placebo device (thirty-one fractures) daily for twenty minutes at home for ten weeks. The two types
of devices were identical except that the placebo devices emitted no ultrasound energy. Clinical examination was
performed and radiographs were made at one, two, three, four, five, six, eight, ten, twelve, and sixteen weeks after
the fracture by each site investigator. The time to union was significantly shorter for the fractures that were treated
with ultrasound than it was for those that were treated with the placebo (mean [and standard error], 61 +/- 3 days
compared with 98 +/- 5 days; p < 0.0001). Each radiographic stage of healing also was significantly accelerated in
the group that was treated with ultrasound as compared with that treated with the placebo. Compared with treatment
with the placebo, treatment with ultrasound was associated with a significantly smaller loss of reduction (20 +/- 6
per cent compared with 43 +/- 8 per cent; p < 0.01> as determined by the degree of volar angulation, as well as with
a significant decrease in the mean time until the loss of reduction ceased (12 +/- 4 days compared with 25 +/- 4 days;
p < 0.04). We concluded that this specific ultrasound signal accelerates the healing of fractures of the distal radial
metaphysis and decreases the loss of reduction during fracture-healing.

Leinberry, CF., Hammond, NL. 3rd. & Siegfried, JW.:
The role of epineurotomy in the operative treatment of carpal tunnel syndrome.
J Bone Joint Surg Am, 79(4):555-7 1997 Apr.
Abstracts: We conducted a prospective, randomized study to evaluate the effect of epineurotomy on the outcome of
operative treatment of established median-nerve compression in the carpal canal. Fifty hands (forty-four patients)
were randomized into two groups: one group had a release of the transverse carpal ligament alone, and the other had
a release and adjuvant epineurotomy of the median nerve. The groups were similar with regard to age, gender,
duration of symptoms, and preoperative physical findings. All patients had electrophysiological evidence of sensory
delays and fibrillations on preoperative testing. All of the operative procedures were performed by the same
surgeon. The patients were evaluated preoperatively and at one year postoperatively. The follow-up examination
revealed no detectable differences between the two groups with regard to symptoms, objective findings, or
electrophysiological findings. This suggests that epineurotomy of the median nerve offers no benefit compared with
sectioning of the transverse carpal ligament alone.

McQueen, MM., Hajducka, C. & Court-Brown, CM.:
Resdisplaced unstable fractures of the distal radius:
a prospective randomized comparison of four methods of treatment.
J Bone Joint Surg.; May 1996, 78-B, 3:404-409.
Abstracts: We performed a prospective, randomised trial on 120 patients with redisplaced fractures of the distal
radius comparing four methods of treatment. The four treatment groups, each containing 30 patients, were
remanipulation and plaster, open reduction and bone grafting, and closed external fixation with and without
mobilisation of the wrist at three weeks.
The radiological results showed improvement in angulation of the distal radius for the open reduction and bone
grafting group. Functional results at six weeks, three and six months and at one year, however, showed no difference
between any of the four groups. The main influence on final outcome was carpal malalignment which had a
statistically significant negative effect on function.

Sollerman, CJ. & Geijer, M.:
Polyurethane versus silicone for endoprosthetic of the metacarpophalangeal
joints in rheumatoid arthritis.
Scandinavian Journal of Plastic and Reconstructive Surgery and Hand
Surgery 1996, 30, 2:145-150.
Abstracts: In a prospective study 12 patients with rheumatoid arthritis underwent arthroplasty of four
metacarpophalangeal joints. Two different implant materials were randomly used in each hand, polyurethane
(Pellethane) or silicone (Silastic). Eleven patients with 44 (21 silicone; 23 polyurethane) implants were re-examined
4.5 years (range 3-5) postoperatively. No difference was found between the implant materials regarding pain,
stability of the joint or recurrence of the ulnar drift. The mean range of motion was 41 degrees (range 20 degrees-70
degrees) in the polyurethane joints compared with 42 degrees (range 15 degrees-90 degrees) in the silicone joints.
The extension deficit was more pronounced in the silicone (mean 11.4 degrees) than in the polyurethane (mean 5.8
degrees) joints, and clinical signs of synovitis around the implants were more common with the silicone
arthroplasties. Radiographic analysis, performed with conventional radiography and computed tomography (CT)
showed one implant fracture in each group. There was a more pronounced bone resorption around silicone implants,
but more sclerosis around polyurethane implants. Bony spurs interfering with function of the implant were common
with both materials.

Sommerkamp, TG., Seeman, M., Silliman, J., Jones, A., Patterson, S., Walker,
J., Semmler, M., Browne, R. & Ezaki, M.:
Dynamic external fixation of unstable fractures of the distal part of the radius.
A prospective, randomized compararison with static external fixation.
J Bone Joint Surg Am, August 1994, 76, 8:1149-1161.
Abstracts: A prospective, randomized study was done to compare the results of dynamic external fixation (the
Clyburn device) with those of static external fixation (the AO/ASIF device) in the treatment of fifty unstable
fractures of the distal part of the radius. Mobilization of the wrist from neutral to 30 degrees of flexion was begun in
the dynamic-fixator group at approximately two weeks, and full motion, allowing 30 degrees of extension, was
started at approximately four weeks. The external fixation frames in both groups were kept in place for
approximately ten weeks. Mobilization of the wrist in the dynamic-fixator group provided little gain in the mean
motion of the wrist at the time of the removal of the fixator or at the one, six, or twelve-month evaluation. The
static-fixator group had greater flexion of the wrist and radial deviation at the early and late follow-up examinations,
while the dynamic-fixator group demonstrated only greater ulnar deviation one month after the fixator had been
removed. Motion of the wrist in the dynamic-fixator group resulted in a statistically significant loss of radial length
compared with that in the static-fixator group (four millimeters compared with one millimeter, p < 0.001).
Complications were more frequent in the dynamic-fixator group. As evaluated with a modification of the scoring
system of Gartland and Werley, 92 per cent of the results at one year were excellent or good in the static-fixator
group and 76 per cent, in the dynamic-fixator group. The results of this study cannot support the concept of early
mobilization with a dynamic external fixator for the treatment of unstable fractures of the distal part of the radius.

Stahl S; Kaufman T.:
The efficacy of an injection of steroids for medial epicondylitis.
A prospective study of sixty elbows.
J Bone Joint Surg Am, 79(11):1648-52 1997 Nov.
Abstracts: We report the details of a prospective, randomized, double-blind study that was undertaken to analyze the
short-term and long-term effects of the local injection of methylprednisolone to treat medial epicondylitis. Fiftyeight
patients (sixty elbows) were assigned to receive a single injection of 1 per cent lidocaine with either forty
milligrams of methylprednisolone (experimental group) or saline solution (control group); both groups were also
managed with physical therapy and the use of non-steroidal anti-inflammatory drugs. The two groups were not
significantly different with regard to the age and gender of the patients, the duration of the symptoms, the degree of
pain before the injection, or the number of dominant upper limbs involved. Six weeks after the injection, the
experimental group had significantly less pain than the control group (p < 0.03), as determined with a modification
of the grading system of Nirschl and Pettrone. However, the groups did not differ with regard to pain at three
months and at one year. The intensity of pain, as measured on a visual-analog scale, did not differ between the two
groups six weeks and one year after the injection. We believe that the improvement observed in both groups
primarily reflects the natural history of the disorder, and we conclude that the local injection of steroids provides
only short-term benefits in the treatment of medial epicondylitis.

Vang, HF., Staunstrup, H., Mikkelsen, S.:
A comparison of 3 and 5 weeks immobilization for older type 1 and 2 Colles' fractures.
J Hand Surg 1998, 23 B, 3:400-01.
Abstracts: In a prospective study of Colles' fractures, 100 patients with Older type 1 and 2 fractures were
randomized in two groups. One group was immobilized for 3 weeks and the other one for 5 weeks. Both groups
were immobilized with a below-elbow plaster splint. At 1 year follow-up, there were 73 patients with 74 fractures.
Dorsal angulation, radial length, wrist motion, grip strength and pain were measured. There was no significant
difference in the measured parameters in the two groups. We found that 3 weeks of immobilization is a satisfactory
treatment for Older type 1 and 2 Colles' fractures.
 

[Columna]
 
 

Bombardier, C., Esmail, R. & Nachemson, AL.:
Editorial. The Cochrane Collaboration Back Review Group for spinal disorders.
Spine1997 Apr 15; 22, 8: 837-40. [Abstract]

Abstracts:
Van Tulder, MW., Assendelft, WJ., Koes, BW. & Bouter, LM.:
Editorial. Method guidelines for systematic
reviews in the CochraneCollaboration Back Review Group for Spinal Disorders.
Spine 1997 Oct 15; 22, 20:
2323-30.

Abstracts:
Brown, MD.:
Update on chemonucleolysis.
Spine, 21, 24 Suppl:62S-68S 1996 Dec 15.
Abstracts: A review of the world medical literature on chemonucleolysis with an emphasis on recent studies, metaanalyses, and the history of the procedure in North America from a regulatory, social, and medicolegal perspective was performed to determine the current status of chemonucleolysis in the management of disc displacement. The world literature supports the use of chymopapain for chemonucleolysis as a safe and effective alternative to surgical disc excision. The efficacy of chymopapain has been shown by prospective, randomized, placebo-controlled, double-blind trials with a minimum 10-year follow-up period. The safety of chymopapain injection compared with surgery has been demonstrated in meta-analyses and in extensive post-marketing surveillance in the United States and Europe. Clinical studies with collagenase and laboratory studies with chondroitinase ABC have shown that chemonucleolysis can be performed with enzymes other than chymopapain. Clinical trials have been performed with collagenase for chemonucleolysis, but all of the results have not been published. Preclinical research with chondroitinase ABC has demonstrated its usefulness for chemonucleolysis in the animal model, but human trials have not begun.

Cutler, RB., Fishbain, DA., Rosomoff, HL., Abdel-Moty, E., Khalil, TM. & Rosomoff, RS.:
Does nonsurgical pain center treatment of chronic pain return patients to work?
A review and meta-analysis of the literature (see comments).
Spine. 1994 Mar 15; 19, 6: 643-52.
Abstracts: Evidence in the literature relating to return to work as an outcome variable for nonsurgical treatment for
chronic pain was examined. Study selection criteria were as follows: a detailed definition of patient work status,
delineation of work status pre-treatment and at follow-up, and documentation of the proportion of patients employed
at follow-up. Of 171 studies reviewed, 37 fulfilled these selection criteria. Because the data were objective in nature,
they were abstracted by the senior author only. For the coded variables of time to follow-up, proportion of patients
working pre-treatment and at follow-up and number of patients, descriptive statistics and correlations were
calculated. Change in employment status at follow-up was significant (P < .005) for all groups examined. In
addition, comparisons for work outcome between treated patients versus patients rejected due to lack of insurance,
and between treated patients versus patients who dropped out of treatment were both significant (P < .001). The
mean difference in employment at follow-up for treated patients versus those not treated was approximately 50%.
The proportion of patients working increased from 20% to 54% post chronic pain nonsurgical treatment. Correlation
analyses did not find a significant trend in percent employed with time to follow-up. These results indicate that (1)
chronic pain nonsurgical treatment does return patients to work; (2) increased rates of return to work are due to
treatment, and (3) benefits of treatment are not temporary.

Chen, J., Solinger, AB., Poncet, JF. & Lantz, CA.:
Meta-analysis of normative cervical motion.
Spine 1999 Aug 1, 24, 15: 1571-8.
Abstracts: Study design: Meta-analysis of normative cervical range of motion literature performed by applying
summary statistics to range of motion and reliability values reported among studies. Objectives: To identify reliable
and valid methods for measuring active and passive cervical range of motion and to estimate normative values.
Summary of background data: Range of motion studies use a variety of measuring instruments and statistical
analyses, making it difficult to select the most suitable instruments, procedures, and normative values for clinical
application. Reviews of the literature, being limited in scope, have not quantitatively synthesized the literature.
Methods: Range of motion and reliability data were grouped by technology and types of motion, then summarized
by deriving means and variabilities. Clinical validity was assessed by examining discrepancies, variabilities, and
correlations. Change in range of motion as a function of age was determined by comparing range of motion ratios
(fourth:third and seventh:third decades). Results: Nine technologies were identified. Overall, passive motion was
greater than active motion, and range of motion decreased as age increased, with women exhibiting greater range of
motion than men. Variations within each technology were as large as or larger than those between technologies,
indicating that clinical procedures are as important as the accuracy and precision of the technology itself. Reliability
has not been adequately tested for the majority of technologies. Conclusions: Clinical procedures appear to be as
important as accuracy and precision in determining the reported range of motion values. Further research is needed
to establish a gold standard for normative values and to identify an instrument that is reliable for all motions.

Deyo, RA.:
Drug therapy for back pain. Which drugs help which patients?.
Spine. 1996 Dec 15; 21, 24: 2840- 9; discussion 2849-50.
Abstracts: Study design: A brief review of current literature and issues on drug therapy for low back pain.
Objectives: To identify current knowledge and future research needs related to drug therapy. Summary of
background data: Drug therapy is one of many possible treatment choices for symptom relief in patients with low
back pain. The variety of drugs used suggests that there is no uniquely successful form of drug therapy. One reason
for uncertainty and slow progress in this area is the limited quality of many clinical trials for back pain, with
inadequate description of patients and outcomes being common deficits. Methods: A selective review of randomized
trials and systematic literature syntheses on drug therapy is given. Results: Despite limitations, there is good
evidence to support the efficacy of nonsteroidal anti-inflammatory drugs for acute low back pain and fair evidence
for the use of muscle relaxants. There is greater controversy about the use of corticosteroids, which have been
administered orally, intramuscularly, and epidurally. There is conflicting evidence regarding epidural injection of
corticosteroids, but one meta-analysis suggests they may provide a small symptomatic improvement for patients
with radiculopathy. Trials of systemic steroids and antidepressant drugs for managing chronic pain are inconclusive.
The only randomized trial of local anesthetic injection into trigger points suggested that this treatment was
equivalent to that of saline injection, needling without injection, or vapo-coolant spray alone. Conclusion: It seems
reasonable to recommend acetaminophen or nonsteroidal anti-inflammatory drugs for patients with acute back pain,
with efforts to minimize costs and complications. Muscle relaxants and narcotic analgesics may be appropriate for
some patients, but selection criteria are unclear, and these drugs should be prescribed for fixed periods. Drug
treatment for chronic low back pain is less clear, and a current controversy centers on the use of chronic narcotic
analgesics for such patients. Future research should include evaluating combinations of medications, combinations
of medication and physical therapy, systemic corticosteroid therapy, trigger point injections, and narcotic use for
patients with chronic pain. Spinal stenosis is common in the older population, and more drug trials are needed for
this condition.

Dickman, CA., Yahiro, MA., Lu, HT. & Melkerson, MN.:
Surgical treatment alternatives for fixation of
unstable fractures of the thoracic and lumbar spine. A meta-analysis.
Spine. 1994 Oct 15; 19, 20 Suppl: 2266S-2273S.

Ferraz, MB., Tugwell, P., Goldsmith, CH. & Atra, E.:
Meta-analysis of sulfasalazine in ankylosing spondylitis.
J Rheumatol. 1990 Nov; 17, 11: 1482-6.
Abstracts: At present there is no widely accepted therapy for ankylosing spondylitis (AS), a progressive debilitating
disease. The effectiveness of sulfasalazine in AS still lacks strong evidence, as well, the magnitude of its benefit is
unknown. A meta-analysis was carried out to assess the effectiveness of sulfasalazine in AS. A search of the
literature was done using Medline, Index Medicus, the reference lists of articles located and contacting content
experts to reveal unpublished studies. Five randomized controlled trials (RCT) comparing sulfasalazine to placebo
were located and assessed methodologically. The methodologic quality of all 5 RCT was considered satisfactory and
consequently these studies were included in the meta-analysis. The pooled estimate of clinical benefit (and its 95%
confidence interval) favoring sulfasalazine, over and above that observed in the placebo group was as follows:
Duration of morning stiffness -28.2% (-54.6 to -1.8%); severity of morning stiffness -30.6% (-52.5 to -8.7%);
severity of pain -26.7% (-44.3 to -9.1%); general well being -7.1% (-24.3 to 10.0%); erythrocyte sedimentation rate
- 9.2% (-24.8 to 6.4%); and IgA -11.7% (-18.8 to -4.7%). Adverse effects, mostly mild, were more frequently
observed in the sulfasalazine group (odds ratio [OR] = 1.5746, p = 0.1082). The occurrence of dropouts (OR =
1.1554, p = 0.6119) was similar in both groups. Sulfasalazine is a safe and effective drug in the short term treatment
of AS.

Fischgrund, JS., Mackay, M., Herkowitz, HN., Brower, R., Montgomery, DM. & Kurz, LT.:
Degenerative lumbar spondylolisthesis with spinal stenosis:
a prospective, randomized study comparing decompressive laminectomy and arthrodesis
with and without spinal instrumentation [1997 Volvo Award winner in clinical studies].
Spine. 1997 Dec 15; 22, 24: 2807-12.
Abstracts: Study design: This prospective study analyzed the influence of transpedicular instrumented on the
operative treatment of patients with degenerative spondylolisthesis and spinal stenosis. Objectives: To determine
whether the addition of transpedicular instrumented improves the clinical outcome and fusion rate of patients
undergoing posterolateral fusion after decompression for spinal stenosis with concomitant degenerative
spondylolisthesis. Summary of background data: Decompression is often necessary in the treatment of symptomatic
patients who have degenerative spondylolisthesis and spinal stenosis. Results of recent studies demonstrated that
outcomes are significantly improved if posterolateral arthrodesis is performed at the listhesed level. A meta-analysis
of the literature concluded that adjunctive spinal instrumentation for this procedure can enhance the fusion rate,
although the effect on clinical outcome remains uncertain. Methods: Seventy-six patients who had symptomatic
spinal stenosis associated with degenerative lumbar spondylolisthesis were prospectively studied. All patients
underwent posterior decompression with concomitant posterolateral intertransverse process arthrodesis. The patients
were randomized to a segmental transpedicular instrumented or noninstrumented group. Results: Sixty-seven
patients were available for a 2-year follow-up. Clinical outcome was excellent or good in 76% of the patients in
whom instrumentation was placed and in 85% of those in whom no instrumentation was placed (P = 0.45).
Successful arthrodesis occurred in 82% of the instrumented cases versus 45% of the noninstrumented cases (P =
0.0015). Overall, successful fusion did not influence patient outcome (P = 0.435). Conclusions: In patients
undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of
pedicle screws may lead to a higher fusion rate, but clinical outcome shows no improvement in pain in the back and
lower limbs.

Focarile, FA., Bonaldi, A., Giarolo, MA., Ferrari, U., Zilioli, E. & Ottaviani, C.:
Effectiveness of nonsurgical treatment for idiopathic scoliosis.
Overview of available evidence.
Spine. 1991 Apr; 16, 4: 395-401.
Abstracts: To define further the effectiveness of nonsurgical therapy for idiopathic scoliosis, predefined criteria were
established for selection and data retrieval from studies of therapy and natural history, and the results were
synthesized quantitatively. Only studies of patients with no more than a 50 degree Cobb angle scoliosis were
considered. Twenty-four reports were eligible. There was a fivefold proportion of failures among patients with
scoliosis greater than 30 degrees at the start of therapy but no difference in progression between different kinds of
nonsurgical therapies or between treated and untreated patients; these were the main findings of this quantitative
analysis. These data cannot be used to prove the effectiveness or ineffectiveness of nonsurgical therapy for
idiopathic scoliosis, and experimental controlled studies of different therapies seem to be justified both on ethical
and scientific grounds. The findings of this overview can be used for their planning.

Gibson, JN., Grant, IC. & Waddell, G.:
The Cochrane review of surgery for lumbar disc prolapse and
degenerative lumbar spondylosis.
Spine 1999 Sep 1, 24, 17: 1820-32.
Abstracts: Study design: A Cochrane review of randomized controlled trials. Objectives: To collate the scientific
evidence on surgical management for lumbar-disc prolapse and degenerative lumbar spondylosis. Summary of
background data: Surgical investigations and interventions account for as much as one third of the health care costs
for spinal disorders, but the scientific evidence for most procedures still is unclear. Methods: A highly sensitive
search strategy identified all published randomized controlled trials. Cochrane methodology was used for metaanalysis
of the results. Results: Twenty-six randomized controlled trials of surgery for lumbar disc prolapse and 14 trials of
surgery for degenerative lumbar spondylosis were identified. Methodologic weaknesses were found in many of the trials.
Only one trial directly compared discectomy and conservative management. Meta-analyses showed that surgical
discectomy produces better clinical outcomes than chemonucleolysis, which is better than placebo. Three trials
showed no difference in clinical outcomes between microdiscectomy and standard discectomy, but in three other
studies, both produced better results than percutaneous discectomy. Three trials showed that inserting an interposition
membrane after discectomy does not significantly reduce scar formation or alter clinical outcomes. Five heterogeneous
trials on spinal stenosis and degenerative spondylolisthesis permit very limited conclusions.There were nine trials of
instrumented versus noninstrumented fusion: Meta-analysis showed that instrumentation may facilitate fusion but does not
improve clinical outcomes.
Conclusions: There is now strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis
versus placebo. There is considerable evidence on the clinical effectiveness of discectomy for carefully selected patients
with sciatica caused by lumbar disc prolapse that fails to resolve with conservative management. There its no scientific
evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared
with natural history, placebo, or conservative management. The Cochrane reviews will be updated continuously as other
trials become available.

Haher, TR., Merola, A., Zipnick, RI., Gorup, J., Mannor, D. & Orchowski, J.:
Meta-analysis of surgical outcome in adolescent idiopathic scoliosis.
A 35-year English literature review of 11,000 patients.
Spine. 1995 Jul 15; 20, 14: 1575-84.
Abstracts: Study design. Meta-analysis of the English literature on the surgical treatment of adolescent idiopathic
scoliosis. Objective. To gather comparable data from a number of different sources and combine the data to create a
larger, more statistically significant pool of information for the analysis of surgical outcome. Summary of
background data. Meta-analysis is a technique of scientific literature review used in outcome evaluation of medical
treatment. This technique has been applied to the surgical outcome of adolescent idiopathic scoliosis. Methods. A
structured literature review was performed that cross-referenced English literature articles pertaining to the surgical
treatment of adolescent idiopathic scoliosis with a focus on patient-based outcomes. Measures of patient satisfaction
were compared with process measures of care. Results. A number of patients (10,989) were reviewed in 139 patient
populations. Unspecified curve types (9424) and King curve types (1565) were reviewed over a 35-year period from
1958 to 1993. Of the patients, 87.32% were studied retrospectively and 12.70% prospectively. Effect-weighted
follow-up was 6.8 years. Only studies with complete process and patient data for unspecified or King curve types
were included for satisfaction correlation calculations. Pearson product moment correlation for n = 33 studies, n' =
2926 patients revealed a positive r' = 0.628 correlation between degree of curve correction and percent satisfaction
per study. To determine the degree of curvature correction resulting in patient satisfaction, a stepwise multiple linear
regression analysis was performed with level of confidence (P < or = 0.05). Of significance was that the degree of
curvature corrected accounted for all the satisfaction variance predicted. A significant correction exists between
degree of curve correction and percent of patients satisfied. The percent of correction and the Group type (either
unspecified or King classified), did not significantly alter this prediction. The best predictor of satisfaction appears
to be degree of curve correction according to these data. Conclusion. Patients appear to be more satisfied by the
magnitude of curve correction rather than the percent of curve correction. The degree of curvature before surgery
did not predict patient satisfaction. Pearsons r' = 0.045. Satisfaction appears to be best predicted by the degree of
correction only and not by the percent curve correction, the curve magnitude before surgery, nor the Group type
(King, unspecified). Patient satisfaction is subjective. It does not reflect the benefits of surgery with respect to the
future preservation of pulmonary function in thoracic curves nor the prevention of osteoarthritis in lumbar curves.

Haher, TR., Gorup, JM., Shin, TM., Homel, P., Merola, AA., Grogan,
DP., Pugh, L., Lowe, TG. & Murray, M.:
Results of the Scoliosis Research Society instrument for evaluation of surgical outcome
in adolescent idiopathic scoliosis. A multicenter study of 244 patients.
Spine 1999 Jul 15, 24, 14: 1435-40.
Abstracts: Study design: An outcome questionnaire was constructed to evaluate patient satisfaction and performance
and to discriminate among patients with adolescent idiopathic scoliosis. Objectives: To determine reliability and
validity in a new quality-of-life instrument for measuring progress among scoliosis patients. Summary of
background data: Meta-analysis of the surgical treatment of adolescent idiopathic scoliosis determined that a
uniform assessment of outcome did not exist. In addition, patient measures of well-being as opposed to process
measures (e.g., radiographs) were not consistently reported. This established the need for a standardized
questionnaire to assess patient measures in conjunction with process measures. Methods: The instrument consists of
24 questions divided into seven equally weighted domains as determined by factor analysis: pain, general selfimage,
postoperative self-image, general function, overall level of activity, postoperative function, and satisfaction.
The questionnaire takes approximately 5 minutes to complete and is taken at predetermined time intervals. A total of
244 of patients from three different sites responded to the questionnaire. Results: The reliability based on internal
consistency was confirmed with a Cronbach's alpha coefficient greater than 0.6 for each domain. In addition,
acceptable correlation coefficient values greater than 0.68 were obtained for each domain by the test-retest method
on normal controls. Similarly; to establish validity of the questionnaire, responses of normal high school students
were compared with that of the patients. Consistent differences were noted in the domains between the two groups
with P < 0.003. The largest differences were in pain (control, 29.96 +/- 0.20; patient, 13.23 +/- 5.55) and general
level of activity (control, 14.96 +/- 0.20; patient, 12.16 +/- 3.23). Examination of the relationship between the
domains and patient satisfaction showed that pain correlates with satisfaction to the greatest degree (Pearson's
correlation co-efficient, r = -0.511; P < 0.001), followed by self-image (r = 0.412; P < 0.001). Conclusions: This
questionnaire addresses patient measures for evaluation of outcome in adolescent idiopathic scoliosis surgery by
examining several domains. It also allows for dynamic monitoring of scoliosis patients as they become adults. This
is a validated instrument with good reliability measures.

Haselkorn, JK., Turner, JA., Diehr, PK., Ciol, MA. & Deyo, RA.:
Meta-analysis. A useful tool for the spine researcher.
Spine 1994 Sep 15;19(18 Suppl): 2076S-2082S.

Abstracts:

Hoffman, RM., Kent, DL. & Deyo, RA.:
Diagnostic accuracy and clinical utility of thermography for lumbar
radiculopathy. A meta-analysis [see comments].
Spine. 1991 Jun; 16, 6: 623-8.
Abstracts: The role of thermography for diagnosing lumbar radiculopathy was evaluated by literature review and
meta-analysis. From 81 relevant citations, 28 studies could be analyzed for diagnostic-accuracy data (sensitivity and
specificity) and method. Diagnostic-accuracy data varied significantly between studies; therefore meaningful pooled
summary statistics could not be reported. Twenty-seven studies had major methodologic flaws including biased test
interpretations, faulty cohort assembly, poor clinical descriptions, and small sample size. The only study of
reasonably high quality found no discriminant value for liquid-crystal thermography. The role of thermography
remains unclear. Rigorous clinical research is required to establish its diagnostic accuracy and clinical utility.
Thermography cannot be recommended currently for routine clinical use in evaluating low-back pain.

Hurwitz, EL., Aker, PD., Adams, AH., Meeker, WC. & Shekelle, PG.:
Manipulation and mobilization of the cervical spine.
A systematic review of the literature [see comments].
Spine. 1996 Aug 1; 21, 15: 1746-59; discussion 1759-60.
Abstracts: Study design: Cervical spine manipulation and mobilization were reviewed in an analysis of the literature
from 1966 to the present. Objectives: To assess the evidence for the efficacy and complications of cervical spine
manipulation and mobilization for the treatment of neck pain and headache. Summary of background data: Although
recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is
known about its efficacy for neck pain and headache. Methods: A structured search of four computerized
bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine
manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality.
The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients'
pain status. Results: Two of three randomized controlled trials showed a short-term benefit for cervical mobilization
for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation
with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual
analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared
with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that
spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for
cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations. Conclusions: Cervical
spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain
and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be
considered because of the possibility of permanent impairment or death.

Jonsson, B., Annertz, M., Sjoberg, C. & Stromqvist, B.:
A prospective and consecutive study of surgically
treated lumbar spinal stenosis. Part II:
Five-year follow-up by an independent observer.
Spine. 1997 Dec 15; 22, 24: 2938-44.
Abstracts: Study design: A prospective and consecutive study of surgical results obtained during serial follow-up
investigations in patients who underwent surgery for central lumbar spinal stenosis. Objectives: To evaluate the
result after surgical decompression for lumbar spinal stenosis, at regular intervals after surgery, and to correlate
these results with values for preoperative parameters; special interest was focused on the results in relation to the
degree of constriction of the spinal canal. Summary of background data: The outcome after surgery for spinal
stenosis is debatable; long-term follow-up investigations have indicated deterioration with passing time. Results of
studies in nonsurgical patients have demonstrated that the symptoms do not progress with time. Results of a metaanalysis
of the literature on surgical results have demonstrated a wide variation of outcomes. Material and methods: In a
prospective study, 105 consecutive patients who underwent surgical decompression (laminectomy with facet
preserving technique, but no fusion) were evaluated at follow-up examinations 4 months and 1, 2, and 5 years after
surgery. At the follow-up examinations, the patient's opinion on the surgical result was registered, using a four-grade scale.
The occurrence of pain at rest and at night was registered, as well as the patient's walking ability. Statistical analysis
was performed, relating the surgical results to patient age, gender, preoperative duration of symptoms and
radiographically observed constriction as described in Part I of this study. The radiologist was blinded to patient outcome.
Logistic regression analysis was performed. Results: During the follow-up period, 19 patients underwent reoperation,
consisting of fusion to treat lumbar pain (n = 4), repeat decompression because of progressive stenosis (n = 13),
and repairs in response to surgical complications (n = 2). Follow-up results: The result, related to the recurrence of
leg symptoms, deteriorated with passing time. Excellent results were reported by 63% to 67% at 4- month and
2-year follow-ups compared with 52% at the 5-year follow-up. There was a correlation between the constriction
of the spinal canal and the outcome at all intervals. Patients with an anteroposterior diameter of 6 mm or less at the
narrowest site had significantly better results. The logistic regression analysis demonstrated a significant correlation
between a severe reduction of the anteroposterior diameter and excellent results and a tendency toward better results
in patients with a shorter preoperative duration of symptoms. Improvement of walking ability was also associated with
a pronounced constriction of the spinal canal. Conclusion: The results after surgical decompression in patients with
central spinal stenosis deteriorated with time. There was a significant correlation between good result and pronounced
constriction of the spinal canal. Patients with a preoperative duration of symptoms of less than 4 years and patients
with no preoperative back pain tended to have better surgical outcomes. The reoperation rate was 18% within 5 years.
When surgery for spinal stenosis is contemplated, these prognostic factors should be taken into consideration: The
"ideal patient" has a pronounced constriction of the spinal canal, insignificant lower back pain, no concomitant disease
affecting walking ability, and a symptom duration of less than 4 years.

Kesling, KL. & Reinker, KA.:
Scoliosis in twins. A meta-analysis of the literature and report of six cases.
Spine. 1997 Sep 1; 22, 17: 2009-14; discussion 2015.
Abstracts: Study design: This study is a meta-analysis of the world's literature on adolescent idiopathic scoliosis in
monozygotic and dizygotic twins. Additionally, six previously unreported cases of scoliosis in twins are presented.
Objectives: To compare and contrast the concordance, severity, and curve patterns in monozygotic and dizygotic
twins with adolescent idiopathic scoliosis in an attempt to document a genetic etiology and delineate inheritance
patterns for adolescent idiopathic scoliosis. Summary of background data: There are numerous case reports of twins
sets with adolescent idiopathic scoliosis. However, this data has not been previously analyzed as a single data base.
Methods: The literature was searched for cases of twins with adolescent idiopathic scoliosis, and six cases of
patients treated by authors were added. One hundred cases of sets of twins were discovered, 68 of which had
sufficient data for comparative analysis. Each set was evaluated for monozygosity, concordance of scoliosis, curve
pattern, and severity of curve. Results: Thirty-seven sets of twins were monozygous, and 31 sets were dizygous.
Concordance was 73% among monozygous twins and 36% among dizygous twins. The difference is statistically
significant at P < 0.003. Curve severity could be compared in 20 sets of monozygous twins and 16 sets of dizygous
twins. Among monozygous twins, there was a correlation coefficient of r = 0.399 (P < 0.126). Curve pattern
comparison was not statistically significant. Conclusions: Monozygous twins have a significantly higher rate of
concordance than dizygous twins, and the curves in monozygous twins develop and progress together. Based on
these data, there is strong evidence for a genetic etiology for adolescent idiopathic scoliosis.

Kinnear, WJ. & Johnston, ID.:
Does Harrington instrumentation improve pulmonary function in adolescents
with idiopathic scoliosis? A meta-analysis.
Spine. 1993 Sep 1; 18, 11: 1556-9.
Abstracts: A meta-analysis of the effects of Harrington instrumentation on vital capacity in adolescent patients with
idiopathic scoliosis was conducted in an attempt to clarify the conflicting conclusions of different studies. Thirty eight
studies were assessed. Those that did not prevent sufficient statistical information and those that did not allow for
normal growth during the interval between tests were excluded. The five studies remaining for analysis,
involving a total of 173 patients, showed an increase in mean vital capacity ranging from 2% to 11% of predicted
vital capacity. The weighted mean effect size for the five studies analyzed was 0.22 with 95% confidence intervals
of 0.01-0.43. The authors conclude that Harrington instrumentation leads to a small but statistically significant
improvement in vital capacity.

Niggemeyer, O., Strauss, JM. & Schulitz, KP.:
Comparison of surgical procedures for degenerative lumbar spinal stenosis:
a meta-analysis of the literature from 1975 to 1995.
Eur Spine J. 1997; 6, 6: 423-9.
Abstracts: Therapy for spinal stenosis remains difficult. The possibilities for conservative management are limited
and not satisfactory in the more severe cases. Various surgical procedures are possible, such as decompression,
decompression and fusion without instrumentation and decompression and fusion with instrumentation. The aim of
our meta-analysis was to compare the postoperative results of these three surgical techniques in the literature and,
thus, to establish a treatment of choice for degenerative lumbar spinal stenosis. Via Medline, 30 articles met the
inclusion criteria for our study, leading to a total number of 1668 cases being included in the meta-analysis. The
evaluation was made according to our own definition of outcomes, based on criteria most commonly used in the
studies reviewed. We found that in patients suffering degenerative spinal stenosis for up to 8 years, decompression
without fusion showed the best results. For a duration of symptoms of 15 years or more, decompression with
instrumented fusion had the best results. Analysing all postoperative outcomes, decompression is the surgical
procedure with the highest rate of success and the fewest complications, followed by decompression with
instrumented fusion. In surgery for degenerative lumbar spinal stenosis, decompression and fusion without
instrumentation was the least successful procedure. As patients suffering from a degenerative spinal stenosis often
are elderly, operations are risky and place a strain on them. This review of the literature shows that the least invasive
surgical procedure can obtain the best results if the correct diagnosis is made and if the operation is carried out
within the first years of the disease.

Olmarker, K. & Larsson, K.:
Tumor necrosis factor alpha and nucleus-pulposus-induced nerve root injury.
Spine. 1998 Dec 1; 23, 23: 2538-44.
Abstracts: Study design: The effects of nucleus pulposus and various treatments to block tumor necrosis factor alpha
activity were evaluated in an experimental set-up using immunohistochemistry and nerve conduction velocity
recordings. Objectives: To assess the presence of tumor necrosis factor alpha in pig nucleus pulposus cells, and to
see if block of tumor necrosis factor alpha also blocks the nucleus-pulposus-induced reduction of nerve root
conduction velocity. Summary and background data: A meta-analysis of observed effects induced by nucleus
pulposus revealed that these effects might relate to one specific cytokine-tumor necrosis factor alpha. Methods:
Series-1: Cultured nucleus pulposus cells were stained immunohistologically with a monoclonal antibody for tumor
necrosis factor alpha. Series-2: Nucleus pulposus was harvested from lumbar discs and applied to the
sacrococcygeal cauda equina in 13 pigs autologously. Four pigs received 100 mg of doxycycline intravenously; five
pigs had a blocking monoclonal antibody to tumor necrosis factor alpha applied locally in the nucleus pulposus, and
four pigs remained nontreated, forming a control group. Three days after the application, the nerve root conduction
velocity was determined over the application zone by local electrical stimulation. Results: Series-1: Tumor necrosis
factor alpha was found to be present in the nucleus pulposus cells. Series-2: The selective antibody to tumor necrosis
factor alpha limited the reduction of nerve conduction velocity, although in comparison with the control group this
was not statistically significant. However, treatment with doxycycline significantly blocked the nucleus-pulposus induced
reduction of conduction velocity. Conclusion: For the first time, a specific substance, tumor necrosis factor alpha, has
been linked to the nucleus-pulposus-induced effects of nerve roots after local application. Although the effects of this
substance may be synergistic with those of other similar substances, the data of the current study may be of significant
importance for the continued understanding of nucleus pulposus' biologic activity, and of possible potential use for future
strategies in managing sciatica.

Ottenbacher, K. & DiFabio, RP.:
Efficacy of spinal manipulation/mobilization therapy. A meta-analysis.
Spine. 1985 Nov; 10, 9: 833-7.
Abstracts: A quantitative review (meta-analysis) was undertaken to synthesize existing evidence on the efficacy of
joint mobilization and manipulation and expose consumers of rehabilitation research to the methods and procedures
of quantitative reviewing. Potentially relevant studies were obtained through a computer-assisted bibliographic
search of the Index Medicus data base and through examination of references contained in retrieved studies. A total
of 57 titles were potentially relevant to manipulation/mobilization, but only nine met the prespecified criteria for
inclusion in the quantitative review. Data analysis indicated that studies not employing random assignment were
more likely to produce results supporting the use of manipulation/mobilization therapies. The effects in favor of
manipulation and mobilization were greater when manual therapy was provided in conjunction with other forms of
treatment and were also greater when the treatment effects were measured immediately following therapy. In
addition, hypotheses tests appearing in journals published in the United States showed manipulation/mobilization
less effective in comparison with reports appearing in English language journals published outside the United States.
The results provided only limited empirical support for spinal mobilization and manipulation when used to treat
pain, flexibility limitations, and impairment in physical activity.

Rowe, DE., Bernstein,SM., Riddick,MF., Adler, F., Emans, JB. & Gardner-Bonneau, D.:
A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis.
J.Bone Joint Surg-Am, 79 (5): 664-74 May 1997.
Abstracts: With use of data culled from twenty studies, members of the Prevalence and Natural History Committee
of the Scoliosis Research Society conducted a meta-analysis of 1910 patients who had been managed with bracing
(1459 patients), lateral electrical surface stimulation (322 patients), or observation (129 patients) because of
idiopathic scoliosis. Three variables - the type of treatment, the level of maturity, and the criterion for failure - were
analyzed to determine which had the greatest impact on the outcome. We also examined the effect of the type of
brace that was used and the duration of bracing on the success of treatment. The number of failures of treatment in
each study was determined by calculating the total number of patients who had unacceptable progression of the
curve (as defined in the study), who could not comply with or tolerate treatment, or who had an operation. The
percentage of patients who completed a given course of treatment without failure, adjusted for the sample sizes of
the studies in which that treatment was used, yielded the weighted mean proportion of success for that treatment.
The weighted mean proportion of success was 0.39 for lateral electrical surface stimulation, 0.49 for observation
only, 0.60 for bracing for eight hours per day, 0.62 for bracing for sixteen hours per day, and 0.93 for bracing for
twenty-three hours per day. The twenty-three-hour regimens were significantly more successful than any other
treatment (p < 0.0001). The difference between the eight and sixteen-hour regimens was not significant, with the
numbers available. Although lateral electrical surface stimulation was associated with a lower weighted mean
proportion of success than observation only, the difference was not significant, with the numbers available. This
meta-analysis demonstrates the effectiveness of bracing for the treatment of idiopathic scoliosis. The weighted mean
proportion of success for the six types of braces included in this review was 0.92, with the highest proportion (0.99)
achieved with the Milwaukee brace. We found that use of the Milwaukee brace or another thoracolumbosacral
orthosis for twenty-three hours per day effectively halted progression of the curve. Bracing for eight or sixteen hours
per day was found to be significantly less effective than bracing for twenty-three hours per day (p < 0.0001).

Stasikelis, PJ., Pugh, LI. & Allen, BL. Jr.:
Surgical corrections in scoliosis: a meta-analysis.
J Pediatr Orthop B. 1998 Apr; 7(2): 111-6.
Abstracts: A meta-analysis of the acute correction outcomes in adolescent idiopathic scoliosis is reported. Posterior
instrumentation systems generally gave similar coronal plane corrections with average corrections for differing
systems ranging from 48% to 67%. There was significant overlap of corrections reported for each of the systems.
Anterior instrumentation gave better results with average corrections ranging from 71% to 93%. No instrumentation
demonstrated a consistent ability to restore a normal thoracic kyphosis, but all seemed to maintain preoperative
kyphosis measures. All systems, including newer multihook systems, showed a small loss of lumbar lordosis
postoperatively. The available data demonstrates that no posterior implant produces vertebral derotation.

Saifuddin, A., White, J., Sherazi, Z., Shaikh, MI., Natali, C., Ransford, AO.:
Osteoid osteoma and osteoblastoma of the spine.
Factors associated with the presence of scoliosis.
Spine 1998 Jan 1, 23, 1: 47-53.
Abstracts: Study design: A retrospective study of 44 museum cases of spinal osteoid osteoma or osteoblastoma
and a meta-analysis using 421 additional cases from a review of the literature. Objectives: To identify the factors that are
associated with the development of scoliosis in these patients. Summary of background data: Painful scoliosis is a
well recognized presentation of spinal osteoid osteoma and osteoblastoma and is considered to be secondary to pain
provoked muscle spasm on the side of the lesion. Previous studies have been based on small numbers of patients that
did not permit statistical validation of the reported observations. Methods: Eight factors were assessed including:
age, gender, duration of symptoms, site of lesion in the spine, vertebral level of lesion, site of lesion in the individual
vertebra, type of lesion, and Cobb angle at presentation. Reports were reviewed only if the presence or absence of
scoliosis could be determined. Statistical analyses initially were performed on the museum cases and then on a
combination of museum cases and cases from the literature. Results: Overall, 63% of subjects had scoliosis. The
lesions were typically present on the concave aspect of the curve. Three cases of scoliosis from the literature
involved lesions that were reported to be on the convexity. Scoliosis is significantly more common in cases of
osteoid osteoma than in cases of osteoblastoma (P < 0.0001); lesions are more common in the thoracic and lumbar
regions than in the cervical region (P < 0.0001), in lower cervical region than in the upper cervical region (P value =
0.0027), and they are more commonly located to one side of the midline (P < 0.0001). Age, gender, and duration of
symptoms were of no significance. Conclusions: The findings support the concept that scoliosis is secondary to
asymmetric muscle spasm in patients with spinal osteoid osteoma or osteoblastoma.

Turner, JA., Ersek, M. & Herron, L:
Surgery for lumbar spinal stenosis: Attempted meta-analysis of the literature.
Spine, 17: 1-8, 1992.
Abstracts: A meta-analysis was undertaken to determine the effects of surgery for lumbar spinal stenosis on pain and
disability. Seventy-four journal articles met inclusion criteria and were independently reviewed by two readers. On
average, 64% of patients treated surgically for lumbar spinal stenosis were reported to have good-to-excellent
outcomes. However, there was wide variation across studies in the percentage with good outcomes. Few patient
characteristics were found to predict outcome. Major deficits in study design, analysis, and reporting were common,
and these precluded firm conclusions.

Turner, JA., Herron, L. & Deyo, RA.:
Meta-analysis of the results of lumbar spine fusion.
Acta Orthop Scand Suppl, 251():120-2 1993.
Turner, JA.:
Educational and behavioral interventions for back pain in primary care.
Spine. 1996 Dec 15; 21, 24: 2851-7; discussion 2858-9.
Abstracts: Study design and objectives: A review of the literature was undertaken to identify and summarize
randomized trials of educational, cognitive, and behavioral interventions for people with chronic low back pain.
Summary of background data: Studies of back schools have varied widely in patient characteristics, back school
length and content, and comparison treatment. The available evidence suggests that back schools do not affect longterm
outcomes of people with back pain. Methods: MEDLINE and PsycLIT databases were searched to identify
randomized trials of cognitive and behavioral treatments for chronic low back pain. Outcome data were extracted
from articles that met the meta-analysis inclusion criteria. Results: The meta-analysis found that cognitive and
behavioral treatments were superior to control conditions after treatment on measures of chronic low back pain, pain
behavior, and disability. Follow-up comparisons of cognitive and behavioral treatments versus control conditions
were not available. This meta-analysis did not find cognitive and behavioral therapies to differ from other active
treatments on specific outcome measures, although only a few studies were available for each measure. Conclusion:
It may be useful to incorporate cognitive-behavioral interventions in primary care settings, but additional research is
needed to evaluate their efficacy in improving specific outcomes.

Watts, RW. & Silagy, CA.:
A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica.
Anaesthesia and Intensive Care 1995 23: 564-9.

Abstracts:
Patrick, CAJ., Vroomen, de Krom, Marc CTFM., Wilmink, Jan T., Kester,
Arnold D.M. & Knottnerus, J. Andre.:
Lack of effectiveness of bed rest for sciatica.
N England J Med., 1999 February, 340, 6:11.

Abstracts:
Van den Hoogen, HM., Koes, BW., van Eijk, JT. & Bouter, LM.:
On the accuracy of history, physical examination, and erythrocyte sedimentation rate
in diagnosing low back pain in general practice. A criteria based review of the literature [see comments].
Spine. 1995 Feb 1; 20, 3: 318-27.
Abstracts: Study design. A criteria-based review of the literature was conducted regarding the accuracy of history,
physical examination, and erythrocyte sedimentation rate in diagnosing low back pain. Objectives. To perform
metaanalysis of the literature regarding signs and symptoms in diagnosing radiculopathy, ankylosing spondylitis,
and vertebral cancer. Summary of background data. Diagnosing low back pain, especially in general practice, depends
largely on history taking, physical examination, and the erythrocyte sedimentation rate. No previous review has
assessed the diagnostic accuracy of signs and symptoms in a systematic way, taking into account the methodological
quality of studies. Methods. The literature was reviewed for relevant studies. Retrieved studies were independently
rated for methodological quality by two reviewers. The reported sensitivity and specificity in the rated studies were
reviewed. Results. Thirty-six eligible studies were retrieved. Major methodological shortcomings were observed, and
only 19 studies scored > or = 55 points (maximal score 100). Not one single test appeared to have high sensitivity
and high specificity in radiculopathy. The combined history and the erythrocyte sedimentation rate had relatively high
diagnostic accuracy in vertebral cancer. Getting out of bed at night and reduced lateral mobility
seemed to be the only moderately accurate items in ankylosing spondylitis. Conclusions. Additional studies that take
into account the shortcomings identified would be needed to produce definite conclusions. Few of the studied signs
and symptoms seemed to be valuable diagnostics for radiculopathy, ankylosing spondylitis, and vertebral cancer.
Reproducibility of signs and symptoms over time might be a valuable diagnostic criterion. However, this was
neglected in almost all studies.

Waddell, G., Feder, G. & Lewis, M.:
Systematic reviews of bed rest and advice to stay active for acute low back pain.
Br J Gen Pract 1997; 47:647-652.

Abstracts:

Carragee, EJ.:
Single-level posterolateral arthrodesis, with or without posterior decompression, for the
treatment of isthmic spondylolisthesis in adults. A prospective, randomized study.
J Bone Joint Surg Am, 79(8):1175-80 1997 Aug.

Abstracts:

Daltroy, LH., Iversen, MD., Larson, MG.et al.
A controlled trial of an educational program to prevent low back injuries.
N England J Med 1997; 337:322-28.

Abstracts:

Grob, D., Humke, T. & Dvorak, J.:
Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis
J Bone Joint Surg Am, 77(7):1036-41 1995 Jul.

Abstracts:

McNeill, TW., Andersson, GB., Schell, B., Sinkora, G., Nelson, J. & Lavender, SA.:
Epidural administration of methylprednisolone and morphine for pain after a spinal operation.
A randomized, prospective, comparative study.
J Bone Joint Surg Am, 77(12):1814-8 1995 Dec.

Abstracts:

Sasso, RC., Williams, JI., Dimasi, N. & Meyer, PR Jr.:
Postoperative drains at the donor sites of iliac-crest bone grafts.
A prospective, randomized study of morbidity at the donor site in patients who had a traumatic
injury of the spine.
J Bone Joint Surg Am, 80(5):631-5 1998 May.

Abstracts:

Van Poppel, MNM., Koes, BW., van der Ploeg, T., Smid, T. & Bouter, LM.:
Lumbar supports and education for the prevention of low back pain in industry.
JAMA 1998; 279:1789-94.

Abstracts:

Brown, MD.:
Update on chemonucleolysis. Spine, 21, 24
Suppl:62S-68S 1996 Dec 15.
Abstracts: A review of the world medical literature on chemonucleolysis with an emphasis on recent studies,
metaanalyses, and the history of the procedure in North America from a regulatory, social, and medicolegal perspective
was performed to determine the current status of chemonucleolysis in the management of disc displacement. The
world literature supports the use of chymopapain for chemonucleolysis as a safe and effective alternative to surgical
disc excision. The efficacy of chymopapain has been shown by prospective, randomized, placebo-controlled,
double-blind trials with a minimum 10-year follow-up period. The safety of chymopapain injection compared
with surgery has been demonstrated in meta-analyses and in extensive post-marketing surveillance in the United
States and Europe. Clinical studies with collagenase and laboratory studies with chondroitinase ABC have shown
that chemonucleolysis can be performed with enzymes other than chymopapain. Clinical trials have been performed
with collagenase for chemonucleolysis, but all of the results have not been published. Preclinical research with
chondroitinase ABC has demonstrated its usefulness for chemonucleolysis in the animal model, but human trials have not begun.

Cutler, RB., Fishbain, DA., Rosomoff, HL., Abdel-Moty, E., Khalil, TM. & Rosomoff, RS.:
Does nonsurgical pain center treatment of chronic pain return patients to work?
A review and meta-analysis of the literature (see comments).
Spine. 1994 Mar 15; 19, 6: 643-52.
Abstracts: Evidence in the literature relating to return to work as an outcome variable for nonsurgical treatment for
chronic pain was examined. Study selection criteria were as follows: a detailed definition of patient work status,
delineation of work status pre-treatment and at follow-up, and documentation of the proportion of patients employed
at follow-up. Of 171 studies reviewed, 37 fulfilled these selection criteria. Because the data were objective in nature,
they were abstracted by the senior author only. For the coded variables of time to follow-up, proportion of patients
working pre-treatment and at follow-up and number of patients, descriptive statistics and correlations were
calculated. Change in employment status at follow-up was significant (P < .005) for all groups examined. In
addition, comparisons for work outcome between treated patients versus patients rejected due to lack of insurance,
and between treated patients versus patients who dropped out of treatment were both significant (P < .001). The
mean difference in employment at follow-up for treated patients versus those not treated was approximately 50%.
The proportion of patients working increased from 20% to 54% post chronic pain nonsurgical treatment. Correlation
analyses did not find a significant trend in percent employed with time to follow-up. These results indicate that (1)
chronic pain nonsurgical treatment does return patients to work; (2) increased rates of return to work are due to
treatment, and (3) benefits of treatment are not temporary.

Chen, J., Solinger, AB., Poncet, JF. & Lantz, CA.:
Meta-analysis of normative cervical motion.
Spine 1999 Aug 1, 24, 15: 1571-8.

Abstracts: Study design: Meta-analysis of normative cervical range of motion literature performed by applying
summary statistics to range of motion and reliability values reported among studies. Objectives: To identify reliable
and valid methods for measuring active and passive cervical range of motion and to estimate normative values.
Summary of background data: Range of motion studies use a variety of measuring instruments and statistical
analyses, making it difficult to select the most suitable instruments, procedures, and normative values for clinical
application. Reviews of the literature, being limited in scope, have not quantitatively synthesized the literature.
Methods: Range of motion and reliability data were grouped by technology and types of motion, then summarized
by deriving means and variabilities. Clinical validity was assessed by examining discrepancies, variabilities, and
correlations. Change in range of motion as a function of age was determined by comparing range of motion ratios
(fourth:third and seventh:third decades). Results: Nine technologies were identified. Overall, passive motion was
greater than active motion, and range of motion decreased as age increased, with women exhibiting greater range of
motion than men. Variations within each technology were as large as or larger than those between technologies,
indicating that clinical procedures are as important as the accuracy and precision of the technology itself. Reliability
has not been adequately tested for the majority of technologies. Conclusions: Clinical procedures appear to be as
important as accuracy and precision in determining the reported range of motion values. Further research is needed
to establish a gold standard for normative values and to identify an instrument that is reliable for all motions.

Deyo, RA.:
Drug therapy for back pain. Which drugs help which patients?.
Spine. 1996 Dec 15; 21, 24: 2840- 9; discussion 2849-50.
Abstracts: Study design: A brief review of current literature and issues on drug therapy for low back pain.
Objectives: To identify current knowledge and future research needs related to drug therapy. Summary of
background data: Drug therapy is one of many possible treatment choices for symptom relief in patients with low
back pain. The variety of drugs used suggests that there is no uniquely successful form of drug therapy. One reason
for uncertainty and slow progress in this area is the limited quality of many clinical trials for back pain, with
inadequate description of patients and outcomes being common deficits. Methods: A selective review of randomized
trials and systematic literature syntheses on drug therapy is given. Results: Despite limitations, there is good
evidence to support the efficacy of nonsteroidal anti-inflammatory drugs for acute low back pain and fair evidence
for the use of muscle relaxants. There is greater controversy about the use of corticosteroids, which have been
administered orally, intramuscularly, and epidurally. There is conflicting evidence regarding epidural injection of
corticosteroids, but one meta-analysis suggests they may provide a small symptomatic improvement for patients
with radiculopathy. Trials of systemic steroids and antidepressant drugs for managing chronic pain are inconclusive.
The only randomized trial of local anesthetic injection into trigger points suggested that this treatment was
equivalent to that of saline injection, needling without injection, or vapo-coolant spray alone. Conclusion: It seems
reasonable to recommend acetaminophen or nonsteroidal anti-inflammatory drugs for patients with acute back pain,
with efforts to minimize costs and complications. Muscle relaxants and narcotic analgesics may be appropriate for
some patients, but selection criteria are unclear, and these drugs should be prescribed for fixed periods. Drug
treatment for chronic low back pain is less clear, and a current controversy centers on the use of chronic narcotic
analgesics for such patients. Future research should include evaluating combinations of medications, combinations
of medication and physical therapy, systemic corticosteroid therapy, trigger point injections, and narcotic use for
patients with chronic pain. Spinal stenosis is common in the older population, and more drug trials are needed for
this condition. [[Volver]] Dickman, CA., Yahiro, MA., Lu, HT. & Melkerson, MN.: Surgical treatment
alternatives for fixation of unstable fractures of the thoracic and lumbar spine. A meta-analysis. Spine. 1994 Oct 15;
19, 20 Suppl: 2266S-2273S.

Abstracts:
Evans, RL., Hendricks, RD., Connis, RT., Haselkorn, JK., Ries, KR. & Mennet, TE.:
Quality of life after spinal cord injury: a literature critique and meta-analysis (1983-1992).
J Am Paraplegia Soc, 17(2):60-6 1994 Apr.

Abstracts: Research articles cross-indexed in Index Medicus under the subject headings "quality of life" (QOL) and
"spinal cord injury" (SCI) were examined in order to compare their relative merits in terms of research design,
sampling techniques and the type of QOL criteria included. Of 3,710 citations indexed for the ten year period 1983
through 1992 under "quality of life," thirty-two research articles (< 1 percent) were cross-indexed with the subject
heading "spinal cord injury." The modal design was a descriptive survey or case study (n = 23 or 72 percent). None
of them were randomized clinical trials. Because of limited rigor of research design and poor validity of
measurements, conclusions about the ability of rehabilitative care to improve the QOL for SCI persons could not be
drawn from the studies reviewed. Meta-analysis indicated that severity of injury is associated with QOL, with more
severe injury being correlated with poorer quality. The critique concludes that QOL research with SCI persons needs
to be better designed and should include more uniform and valid.

Ferraz, MB., Tugwell, P., Goldsmith, CH. & Atra, E.:
Meta-analysis of sulfasalazine in ankylosing spondylitis.
J Rheumatol. 1990 Nov; 17, 11: 1482-6.
Abstracts: At present there is no widely accepted therapy for ankylosing spondylitis (AS), a progressive debilitating
disease. The effectiveness of sulfasalazine in AS still lacks strong evidence, as well, the magnitude of its benefit is
unknown. A meta-analysis was carried out to assess the effectiveness of sulfasalazine in AS. A search of the
literature was done using Medline, Index Medicus, the reference lists of articles located and contacting content
experts to reveal unpublished studies. Five randomized controlled trials (RCT) comparing sulfasalazine to placebo
were located and assessed methodologically. The methodologic quality of all 5 RCT was considered satisfactory and
consequently these studies were included in the meta-analysis. The pooled estimate of clinical benefit (and its 95%
confidence interval) favoring sulfasalazine, over and above that observed in the placebo group was as follows:
Duration of morning stiffness -28.2% (-54.6 to -1.8%); severity of morning stiffness -30.6% (-52.5 to -8.7%);
severity of pain -26.7% (-44.3 to -9.1%); general well being -7.1% (-24.3 to 10.0%); erythrocyte sedimentation rate
- 9.2% (-24.8 to 6.4%); and IgA -11.7% (-18.8 to -4.7%). Adverse effects, mostly mild, were more frequently
observed in the sulfasalazine group (odds ratio [OR] = 1.5746, p = 0.1082). The occurrence of dropouts (OR =
1.1554, p = 0.6119) was similar in both groups. Sulfasalazine is a safe and effective drug in the short term treatment
of AS.

Fischgrund, JS., Mackay, M., Herkowitz, HN., Brower, R., Montgomery, DM. & Kurz, LT.:
Degenerative lumbar spondylolisthesis with spinal stenosis:
a prospective, randomized study comparing decompressive laminectomy and arthrodesis
with and without spinal instrumentation [1997 Volvo Award winner in clinical studies].
Spine. 1997 Dec 15; 22, 24: 2807-12.
Abstracts: Study design: This prospective study analyzed the influence of transpedicular instrumented on the
operative treatment of patients with degenerative spondylolisthesis and spinal stenosis. Objectives: To determine
whether the addition of transpedicular instrumented improves the clinical outcome and fusion rate of patients
undergoing posterolateral fusion after decompression for spinal stenosis with concomitant degenerative
spondylolisthesis. Summary of background data: Decompression is often necessary in the treatment of symptomatic
patients who have degenerative spondylolisthesis and spinal stenosis. Results of recent studies demonstrated that
outcomes are significantly improved if posterolateral arthrodesis is performed at the listhesed level. A meta-analysis
of the literature concluded that adjunctive spinal instrumentation for this procedure can enhance the fusion rate,
although the effect on clinical outcome remains uncertain. Methods: Seventy-six patients who had symptomatic
spinal stenosis associated with degenerative lumbar spondylolisthesis were prospectively studied. All patients
underwent posterior decompression with concomitant posterolateral intertransverse process arthrodesis. The patients
were randomized to a segmental transpedicular instrumented or noninstrumented group. Results: Sixty-seven
patients were available for a 2-year follow-up. Clinical outcome was excellent or good in 76% of the patients in
whom instrumentation was placed and in 85% of those in whom no instrumentation was placed (P = 0.45).
Successful arthrodesis occurred in 82% of the instrumented cases versus 45% of the noninstrumented cases (P =
0.0015). Overall, successful fusion did not influence patient outcome (P = 0.435). Conclusions: In patients
undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of
pedicle screws may lead to a higher fusion rate, but clinical outcome shows no improvement in pain in the back and
lower limbs.

Focarile, FA., Bonaldi, A., Giarolo, MA., Ferrari, U., Zilioli, E. & Ottaviani, C.:
Effectiveness of nonsurgical treatment for idiopathic scoliosis.
Overview of available evidence.
Spine. 1991 Apr; 16, 4: 395-401.
Abstracts: To define further the effectiveness of nonsurgical therapy for idiopathic scoliosis, predefined criteria were
established for selection and data retrieval from studies of therapy and natural history, and the results were
synthesized quantitatively. Only studies of patients with no more than a 50 degree Cobb angle scoliosis were
considered. Twenty-four reports were eligible. There was a fivefold proportion of failures among patients with
scoliosis greater than 30 degrees at the start of therapy but no difference in progression between different kinds of
nonsurgical therapies or between treated and untreated patients; these were the main findings of this quantitative
analysis. These data cannot be used to prove the effectiveness or ineffectiveness of nonsurgical therapy for
idiopathic scoliosis, and experimental controlled studies of different therapies seem to be justified both on ethical
and scientific grounds. The findings of this overview can be used for their planning.

Gibson, JN., Grant, IC. & Waddell, G.:
The Cochrane review of surgery for lumbar disc prolapse and
degenerative lumbar spondylosis.
Spine 1999 Sep 1, 24, 17: 1820-32.
Abstracts: Study design: A Cochrane review of randomized controlled trials. Objectives: To collate the scientific
evidence on surgical management for lumbar-disc prolapse and degenerative lumbar spondylosis. Summary of
background data: Surgical investigations and interventions account for as much as one third of the health care costs
for spinal disorders, but the scientific evidence for most procedures still is unclear. Methods: A highly sensitive
search strategy identified all published randomized controlled trials. Cochrane methodology was used for
metaanalysis of the results. Results: Twenty-six randomized controlled trials of surgery for lumbar disc prolapse
and 14 trials of surgery for degenerative lumbar spondylosis were identified. Methodologic weaknesses were found
in many of the trials. Only one trial directly compared discectomy and conservative management. Meta-analyses
showed that surgical discectomy produces better clinical outcomes than chemonucleolysis, which is better than
placebo. Three trials showed no difference in clinical outcomes between microdiscectomy and standard discectomy,
but in three other studies, both produced better results than percutaneous discectomy. Three trials showed that
inserting an interposition membrane after discectomy does not significantly reduce scar formation or alter clinical outcomes.
Five heterogeneous trials on spinal stenosis and degenerative spondylolisthesis permit very limited conclusions.
There were nine trials of instrumented versus noninstrumented fusion: Meta-analysis showed that instrumentation
may facilitate fusion but does not improve clinical outcomes. Conclusions: There is now strong evidence on the
relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is considerable
evidence on the clinical effectiveness of discectomy for carefully selected patients with sciatica caused by lumbar
disc prolapse that fails to resolve with conservative management. There its no scientific evidence on the
effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with
natural history, placebo, or conservative management. The Cochrane reviews will be updated continuously as other
trials become available.

Haher, TR., Merola, A., Zipnick, RI., Gorup, J., Mannor, D. & Orchowski, J.:
Meta-analysis of surgical outcome in adolescent idiopathic scoliosis.
A 35-year English literature review of 11,000 patients.
Spine. 1995 Jul 15; 20, 14: 1575-84.
Abstracts: Study design. Meta-analysis of the English literature on the surgical treatment of adolescent idiopathic
scoliosis. Objective. To gather comparable data from a number of different sources and combine the data to create a
larger, more statistically significant pool of information for the analysis of surgical outcome. Summary of
background data. Meta-analysis is a technique of scientific literature review used in outcome evaluation of medical
treatment. This technique has been applied to the surgical outcome of adolescent idiopathic scoliosis. Methods. A
structured literature review was performed that cross-referenced English literature articles pertaining to the surgical
treatment of adolescent idiopathic scoliosis with a focus on patient-based outcomes. Measures of patient satisfaction
were compared with process measures of care. Results. A number of patients (10,989) were reviewed in 139 patient
populations. Unspecified curve types (9424) and King curve types (1565) were reviewed over a 35-year period from
1958 to 1993. Of the patients, 87.32% were studied retrospectively and 12.70% prospectively. Effect-weighted
follow-up was 6.8 years. Only studies with complete process and patient data for unspecified or King curve types
were included for satisfaction correlation calculations. Pearson product moment correlation for n = 33 studies, n' =
2926 patients revealed a positive r' = 0.628 correlation between degree of curve correction and percent satisfaction
per study. To determine the degree of curvature correction resulting in patient satisfaction, a stepwise multiple linear
regression analysis was performed with level of confidence (P < or = 0.05). Of significance was that the degree of
curvature corrected accounted for all the satisfaction variance predicted. A significant correction exists between
degree of curve correction and percent of patients satisfied. The percent of correction and the Group type (either
unspecified or King classified), did not significantly alter this prediction. The best predictor of satisfaction appears
to be degree of curve correction according to these data. Conclusion. Patients appear to be more satisfied by the
magnitude of curve correction rather than the percent of curve correction. The degree of curvature before surgery
did not predict patient satisfaction. Pearsons r' = 0.045. Satisfaction appears to be best predicted by the degree of
correction only and not by the percent curve correction, the curve magnitude before surgery, nor the Group type
(King, unspecified). Patient satisfaction is subjective. It does not reflect the benefits of surgery with respect to the
future preservation of pulmonary function in thoracic curves nor the prevention of osteoarthritis in lumbar curves.

Haher, TR., Gorup, JM., Shin, TM., Homel, P., Merola, AA., Grogan, DP.,
Pugh, L., Lowe, TG. & Murray, M.:
Results of the Scoliosis Research Society instrument for evaluation of surgical outcome in adolescent
idiopathic scoliosis.
A multicenter study of 244 patients.
Spine 1999 Jul 15, 24, 14: 1435-40.
Abstracts: Study design: An outcome questionnaire was constructed to evaluate patient satisfaction and performance
and to discriminate among patients with adolescent idiopathic scoliosis. Objectives: To determine reliability and
validity in a new quality-of-life instrument for measuring progress among scoliosis patients. Summary of
background data: Meta-analysis of the surgical treatment of adolescent idiopathic scoliosis determined that a
uniform assessment of outcome did not exist. In addition, patient measures of well-being as opposed to process
measures (e.g., radiographs) were not consistently reported. This established the need for a standardized
questionnaire to assess patient measures in conjunction with process measures. Methods: The instrument consists of
24 questions divided into seven equally weighted domains as determined by factor analysis: pain, general selfimage,
postoperative self-image, general function, overall level of activity, postoperative function, and satisfaction.
The questionnaire takes approximately 5 minutes to complete and is taken at predetermined time intervals. A total of
244 of patients from three different sites responded to the questionnaire. Results: The reliability based on internal
consistency was confirmed with a Cronbach's alpha coefficient greater than 0.6 for each domain. In addition,
acceptable correlation coefficient values greater than 0.68 were obtained for each domain by the test-retest method
on normal controls. Similarly; to establish validity of the questionnaire, responses of normal high school students
were compared with that of the patients. Consistent differences were noted in the domains between the two groups
with P < 0.003. The largest differences were in pain (control, 29.96 +/- 0.20; patient, 13.23 +/- 5.55) and general
level of activity (control, 14.96 +/- 0.20; patient, 12.16 +/- 3.23). Examination of the relationship between the
domains and patient satisfaction showed that pain correlates with satisfaction to the greatest degree (Pearson's
correlation co-efficient, r = -0.511; P < 0.001), followed by self-image (r = 0.412; P < 0.001). Conclusions: This
questionnaire addresses patient measures for evaluation of outcome in adolescent idiopathic scoliosis surgery by
examining several domains. It also allows for dynamic monitoring of scoliosis patients as they become adults. This
is a validated instrument with good reliability measures.

Haselkorn, JK., Turner, JA., Diehr, PK., Ciol, MA. & Deyo, RA.:
Meta-analysis. A useful tool for the spine researcher.
Spine 1994 Sep 15;19(18 Suppl): 2076S-2082S.
Abstracts: Meta-analysis is a systematic and objective methodology for synthesizing research literature. The authors
present the history and definition of meta-analysis, discuss the generic framework for design and implementation of
a meta-analysis, and review the problems and pitfalls that can accompany meta-analyses. Their discussion draws on
practical experience with several meta-analyses of the low back pain literature. Meta-analysis can be used to help
answer the questions about various options for diagnosis and treatment of low back problems and also to point out
gaps in our knowledge base that may have a high priority for research. Meta-analytic methods are an informative
means of addressing health care controversies with major patient management and cost implications.

Hoffman, RM., Kent, DL. & Deyo, RA.:
Diagnostic accuracy and clinical utility of thermography for lumbar
radiculopathy. A meta-analysis [see comments].
Spine. 1991 Jun; 16, 6: 623-8.
Abstracts: The role of thermography for diagnosing lumbar radiculopathy was evaluated by literature review and
meta-analysis. From 81 relevant citations, 28 studies could be analyzed for diagnostic-accuracy data (sensitivity and
specificity) and method. Diagnostic-accuracy data varied significantly between studies; therefore meaningful pooled
summary statistics could not be reported. Twenty-seven studies had major methodologic flaws including biased test
interpretations, faulty cohort assembly, poor clinical descriptions, and small sample size. The only study of
reasonably high quality found no discriminant value for liquid-crystal thermography. The role of thermography
remains unclear. Rigorous clinical research is required to establish its diagnostic accuracy and clinical utility.
Thermography cannot be recommended currently for routine clinical use in evaluating low-back pain.

Hurwitz, EL., Aker, PD., Adams, AH., Meeker, WC. & Shekelle, PG.:
Manipulation and mobilization of the cervical spine.
A systematic review of the literature [see comments].
Spine. 1996 Aug 1; 21, 15: 1746-59; discussion 1759-60.
Abstracts: Study design: Cervical spine manipulation and mobilization were reviewed in an analysis of the literature
from 1966 to the present. Objectives: To assess the evidence for the efficacy and complications of cervical spine
manipulation and mobilization for the treatment of neck pain and headache. Summary of background data: Although
recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is
known about its efficacy for neck pain and headache. Methods: A structured search of four computerized
bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine
manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality.
The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients'
pain status. Results: Two of three randomized controlled trials showed a short-term benefit for cervical mobilization
for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation
with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual
analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared
with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that
spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for
cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations. Conclusions: Cervical
spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain
and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be
considered because of the possibility of permanent impairment or death.

Jonsson, B., Annertz, M., Sjoberg, C. & Stromqvist, B.:
A prospective and consecutive study of surgically treated lumbar spinal stenosis.
Part II: Five-year follow-up by an independent observer.
Spine. 1997 Dec 15; 22, 24: 2938-44.
Abstracts: Study design: A prospective and consecutive study of surgical results obtained during serial follow-up
investigations in patients who underwent surgery for central lumbar spinal stenosis. Objectives: To evaluate the
result after surgical decompression for lumbar spinal stenosis, at regular intervals after surgery, and to correlate
these results with values for preoperative parameters; special interest was focused on the results in relation to the
degree of constriction of the spinal canal. Summary of background data: The outcome after surgery for spinal
stenosis is debatable; long-term follow-up investigations have indicated deterioration with passing time. Results of
studies in nonsurgical patients have demonstrated that the symptoms do not progress with time. Results of a metaanalysis
of the literature on surgical results have demonstrated a wide variation of outcomes. Material and methods: In a
prospective study, 105 consecutive patients who underwent surgical decompression (laminectomy with facet
preserving technique, but no fusion) were evaluated at follow-up examinations 4 months and 1, 2, and 5 years after
surgery. At the follow-up examinations, the patient's opinion on the surgical result was registered, using a four-grade
scale. The occurrence of pain at rest and at night was registered, as well as the patient's walking ability. Statistical
analysis was performed, relating the surgical results to patient age, gender, preoperative duration of symptoms and
radiographically observed constriction as described in Part I of this study. The radiologist was blinded to patient
outcome. Logistic regression analysis was performed. Results: During the follow-up period, 19 patients underwent
reoperation, consisting of fusion to treat lumbar pain (n = 4), repeat decompression because of progressive
stenosis (n = 13), and repairs in response to surgical complications (n = 2). Follow-up results: The result, related
to the recurrence of leg symptoms, deteriorated with passing time. Excellent results were reported by 63% to 67%
at 4- month and 2-year follow-ups compared with 52% at the 5-year follow-up. There was a correlation between
the constriction of the spinal canal and the outcome at all intervals. Patients with an anteroposterior diameter of 6 mm
or less at the narrowest site had significantly better results. The logistic regression analysis demonstrated a significant
correlation between a severe reduction of the anteroposterior diameter and excellent results and a tendency toward
better results in patients with a shorter preoperative duration of symptoms. Improvement of walking ability was also
associated with a pronounced constriction of the spinal canal. Conclusion: The results after surgical decompression in
patients with central spinal stenosis deteriorated with time. There was a significant correlation between good result
and pronounced constriction of the spinal canal. Patients with a preoperative duration of symptoms of less than 4
years and patients with no preoperative back pain tended to have better surgical outcomes. The reoperation rate
was 18% within 5 years. When surgery for spinal stenosis is contemplated, these prognostic factors should be taken
into consideration: The "ideal patient" has a pronounced constriction of the spinal canal, insignificant lower back pain,
no concomitant disease affecting walking ability, and a symptom duration of less than 4 years.

Kesling, KL. & Reinker, KA.:
Scoliosis in twins. A meta-analysis of the literature and report of six cases.
Spine. 1997 Sep 1; 22, 17: 2009-14; discussion 2015.
Abstracts: Study design: This study is a meta-analysis of the world's literature on adolescent idiopathic scoliosis in
monozygotic and dizygotic twins. Additionally, six previously unreported cases of scoliosis in twins are presented.
Objectives: To compare and contrast the concordance, severity, and curve patterns in monozygotic and dizygotic
twins with adolescent idiopathic scoliosis in an attempt to document a genetic etiology and delineate inheritance
patterns for adolescent idiopathic scoliosis. Summary of background data: There are numerous case reports of twins
sets with adolescent idiopathic scoliosis. However, this data has not been previously analyzed as a single data base.
Methods: The literature was searched for cases of twins with adolescent idiopathic scoliosis, and six cases of
patients treated by authors were added. One hundred cases of sets of twins were discovered, 68 of which had
sufficient data for comparative analysis. Each set was evaluated for monozygosity, concordance of scoliosis, curve
pattern, and severity of curve. Results: Thirty-seven sets of twins were monozygous, and 31 sets were dizygous.
Concordance was 73% among monozygous twins and 36% among dizygous twins. The difference is statistically
significant at P < 0.003. Curve severity could be compared in 20 sets of monozygous twins and 16 sets of dizygous
twins. Among monozygous twins, there was a correlation coefficient of r = 0.399 (P < 0.126). Curve pattern
comparison was not statistically significant. Conclusions: Monozygous twins have a significantly higher rate of
concordance than dizygous twins, and the curves in monozygous twins develop and progress together. Based on
these data, there is strong evidence for a genetic etiology for adolescent idiopathic scoliosis.

Kinnear, WJ. & Johnston, ID.:
Does Harrington instrumentation improve pulmonary function in adolescents
with idiopathic scoliosis? A meta-analysis.
Spine. 1993 Sep 1; 18, 11: 1556-9.
Abstracts: A meta-analysis of the effects of Harrington instrumentation on vital capacity in adolescent patients with
idiopathic scoliosis was conducted in an attempt to clarify the conflicting conclusions of different studies. Thirty eight
studies were assessed. Those that did not prevent sufficient statistical information and those that did not allow for
normal growth during the interval between tests were excluded. The five studies remaining for analysis,
involving a total of 173 patients, showed an increase in mean vital capacity ranging from 2% to 11% of predicted
vital capacity. The weighted mean effect size for the five studies analyzed was 0.22 with 95% confidence intervals
of 0.01-0.43. The authors conclude that Harrington instrumentation leads to a small but statistically significant
improvement in vital capacity.

Niggemeyer, O., Strauss, JM. & Schulitz, KP.:
Comparison of surgical procedures for degenerative lumbar spinal stenosis:
a meta-analysis of the literature from 1975 to 1995.
Eur Spine J. 1997; 6, 6: 423-9.
Abstracts: Therapy for spinal stenosis remains difficult. The possibilities for conservative management are limited
and not satisfactory in the more severe cases. Various surgical procedures are possible, such as decompression,
decompression and fusion without instrumentation and decompression and fusion with instrumentation. The aim of
our meta-analysis was to compare the postoperative results of these three surgical techniques in the literature and,
thus, to establish a treatment of choice for degenerative lumbar spinal stenosis. Via Medline, 30 articles met the
inclusion criteria for our study, leading to a total number of 1668 cases being included in the meta-analysis. The
evaluation was made according to our own definition of outcomes, based on criteria most commonly used in the
studies reviewed. We found that in patients suffering degenerative spinal stenosis for up to 8 years, decompression
without fusion showed the best results. For a duration of symptoms of 15 years or more, decompression with
instrumented fusion had the best results. Analysing all postoperative outcomes, decompression is the surgical
procedure with the highest rate of success and the fewest complications, followed by decompression with
instrumented fusion. In surgery for degenerative lumbar spinal stenosis, decompression and fusion without
instrumentation was the least successful procedure. As patients suffering from a degenerative spinal stenosis often
are elderly, operations are risky and place a strain on them. This review of the literature shows that the least invasive
surgical procedure can obtain the best results if the correct diagnosis is made and if the operation is carried out
within the first years of the disease.

Olmarker, K. & Larsson, K.:
Tumor necrosis factor alpha and nucleus-pulposus-induced nerve root injury.
Spine. 1998 Dec 1; 23, 23: 2538-44.
Abstracts: Study design: The effects of nucleus pulposus and various treatments to block tumor necrosis factor
alpha activity were evaluated in an experimental set-up using immunohistochemistry and nerve conduction velocity
recordings. Objectives: To assess the presence of tumor necrosis factor alpha in pig nucleus pulposus cells, and to
see if block of tumor necrosis factor alpha also blocks the nucleus-pulposus-induced reduction of nerve root
conduction velocity. Summary and background data: A meta-analysis of observed effects induced by nucleus
pulposus revealed that these effects might relate to one specific cytokine-tumor necrosis factor alpha. Methods:
Series-1: Cultured nucleus pulposus cells were stained immunohistologically with a monoclonal antibody for tumor
necrosis factor alpha. Series-2: Nucleus pulposus was harvested from lumbar discs and applied to the
sacrococcygeal cauda equina in 13 pigs autologously. Four pigs received 100 mg of doxycycline intravenously; five
pigs had a blocking monoclonal antibody to tumor necrosis factor alpha applied locally in the nucleus pulposus, and
four pigs remained nontreated, forming a control group. Three days after the application, the nerve root conduction
velocity was determined over the application zone by local electrical stimulation. Results: Series-1: Tumor necrosis
factor alpha was found to be present in the nucleus pulposus cells. Series-2: The selective antibody to tumor necrosis
factor alpha limited the reduction of nerve conduction velocity, although in comparison with the control group this
was not statistically significant. However, treatment with doxycycline significantly blocked the nucleus-pulposus
induced reduction of conduction velocity. Conclusion: For the first time, a specific substance, tumor necrosis factor
alpha, has been linked to the nucleus-pulposus-induced effects of nerve roots after local application. Although the
effects of this substance may be synergistic with those of other similar substances, the data of the current study may
be of significant importance for the continued understanding of nucleus pulposus' biologic activity, and of possible
potential use for future strategies in managing sciatica.

Ottenbacher, K. & DiFabio, RP.:
Efficacy of spinal manipulation/mobilization therapy. A meta-analysis.
Spine. 1985 Nov; 10, 9: 833-7.
Abstracts: A quantitative review (meta-analysis) was undertaken to synthesize existing evidence on the efficacy of
joint mobilization and manipulation and expose consumers of rehabilitation research to the methods and procedures
of quantitative reviewing. Potentially relevant studies were obtained through a computer-assisted bibliographic
search of the Index Medicus data base and through examination of references contained in retrieved studies. A total
of 57 titles were potentially relevant to manipulation/mobilization, but only nine met the prespecified criteria for
inclusion in the quantitative review. Data analysis indicated that studies not employing random assignment were
more likely to produce results supporting the use of manipulation/mobilization therapies. The effects in favor of
manipulation and mobilization were greater when manual therapy was provided in conjunction with other forms of
treatment and were also greater when the treatment effects were measured immediately following therapy. In
addition, hypotheses tests appearing in journals published in the United States showed manipulation/mobilization
less effective in comparison with reports appearing in English language journals published outside the United States.
The results provided only limited empirical support for spinal mobilization and manipulation when used to treat
pain, flexibility limitations, and impairment in physical activity.

Rowe, DE., Bernstein,SM., Riddick,MF., Adler, F., Emans, JB. & Gardner-Bonneau, D.:
A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis.
J.Bone Joint Surg-Am, 79 (5): 664-74 May 1997.
Abstracts: With use of data culled from twenty studies, members of the Prevalence and Natural History Committee
of the Scoliosis Research Society conducted a meta-analysis of 1910 patients who had been managed with bracing
(1459 patients), lateral electrical surface stimulation (322 patients), or observation (129 patients) because of
idiopathic scoliosis. Three variables - the type of treatment, the level of maturity, and the criterion for failure - were
analyzed to determine which had the greatest impact on the outcome. We also examined the effect of the type of
brace that was used and the duration of bracing on the success of treatment. The number of failures of treatment in
each study was determined by calculating the total number of patients who had unacceptable progression of the
curve (as defined in the study), who could not comply with or tolerate treatment, or who had an operation. The
percentage of patients who completed a given course of treatment without failure, adjusted for the sample sizes of
the studies in which that treatment was used, yielded the weighted mean proportion of success for that treatment.
The weighted mean proportion of success was 0.39 for lateral electrical surface stimulation, 0.49 for observation
only, 0.60 for bracing for eight hours per day, 0.62 for bracing for sixteen hours per day, and 0.93 for bracing for
twenty-three hours per day. The twenty-three-hour regimens were significantly more successful than any other
treatment (p < 0.0001). The difference between the eight and sixteen-hour regimens was not significant, with the
numbers available. Although lateral electrical surface stimulation was associated with a lower weighted mean
proportion of success than observation only, the difference was not significant, with the numbers available. This
meta-analysis demonstrates the effectiveness of bracing for the treatment of idiopathic scoliosis. The weighted mean
proportion of success for the six types of braces included in this review was 0.92, with the highest proportion (0.99)
achieved with the Milwaukee brace. We found that use of the Milwaukee brace or another thoracolumbosacral
orthosis for twenty-three hours per day effectively halted progression of the curve. Bracing for eight or sixteen hours
per day was found to be significantly less effective than bracing for twenty-three hours per day (p < 0.0001).

Stasikelis, PJ., Pugh, LI. & Allen, BL. Jr.:
Surgical corrections in scoliosis: a meta-analysis.
J Pediatr Orthop B. 1998 Apr; 7(2): 111-6.
Abstracts: A meta-analysis of the acute correction outcomes in adolescent idiopathic scoliosis is reported. Posterior
instrumentation systems generally gave similar coronal plane corrections with average corrections for differing
systems ranging from 48% to 67%. There was significant overlap of corrections reported for each of the systems.
Anterior instrumentation gave better results with average corrections ranging from 71% to 93%. No instrumentation
demonstrated a consistent ability to restore a normal thoracic kyphosis, but all seemed to maintain preoperative
kyphosis measures. All systems, including newer multihook systems, showed a small loss of lumbar lordosis
postoperatively. The available data demonstrates that no posterior implant produces vertebral derotation.

Saifuddin, A., White, J., Sherazi, Z., Shaikh, MI., Natali, C., Ransford, AO.:
Osteoid osteoma and osteoblastoma of the spine.
Factors associated with the presence of scoliosis.
Spine 1998 Jan 1, 23, 1: 47-53.
Abstracts: Study design: A retrospective study of 44 museum cases of spinal osteoid osteoma or osteoblastoma and
a meta-analysis using 421 additional cases from a review of the literature. Objectives: To identify the factors that are
associated with the development of scoliosis in these patients. Summary of background data: Painful scoliosis is a
well recognized presentation of spinal osteoid osteoma and osteoblastoma and is considered to be secondary to pain-
provoked muscle spasm on the side of the lesion. Previous studies have been based on small numbers of patients that
did not permit statistical validation of the reported observations. Methods: Eight factors were assessed including:
age, gender, duration of symptoms, site of lesion in the spine, vertebral level of lesion, site of lesion in the individual
vertebra, type of lesion, and Cobb angle at presentation. Reports were reviewed only if the presence or absence of
scoliosis could be determined. Statistical analyses initially were performed on the museum cases and then on a
combination of museum cases and cases from the literature. Results: Overall, 63% of subjects had scoliosis. The
lesions were typically present on the concave aspect of the curve. Three cases of scoliosis from the literature
involved lesions that were reported to be on the convexity. Scoliosis is significantly more common in cases of
osteoid osteoma than in cases of osteoblastoma (P < 0.0001); lesions are more common in the thoracic and lumbar
regions than in the cervical region (P < 0.0001), in lower cervical region than in the upper cervical region (P value =
0.0027), and they are more commonly located to one side of the midline (P < 0.0001). Age, gender, and duration of
symptoms were of no significance. Conclusions: The findings support the concept that scoliosis is secondary to
asymmetric muscle spasm in patients with spinal osteoid osteoma or osteoblastoma.

Turner, JA., Ersek, M. & Herron, L:
Surgery for lumbar spinal stenosis: Attempted meta-analysis of the literature.
Spine, 17: 1-8, 1992.
Abstracts: A meta-analysis was undertaken to determine the effects of surgery for lumbar spinal stenosis on pain
and disability. Seventy-four journal articles met inclusion criteria and were independently reviewed by two readers.
On average, 64% of patients treated surgically for lumbar spinal stenosis were reported to have good-to-excellent
outcomes. However, there was wide variation across studies in the percentage with good outcomes. Few patient
characteristics were found to predict outcome. Major deficits in study design, analysis, and reporting were common,
and these precluded firm conclusions.

Turner, JA., Herron, L. & Deyo, RA.:
Meta-analysis of the results of lumbar spine fusion.
Acta Orthop Scand Suppl, 251():120-2 1993.
Turner, JA.: Educational and behavioral interventions for back pain in primary care.
Spine. 1996 Dec 15; 21, 24: 2851-7; discussion 2858-9.
Abstracts: Study design and objectives: A review of the literature was undertaken to identify and summarize
randomized trials of educational, cognitive, and behavioral interventions for people with chronic low back pain.
Summary of background data: Studies of back schools have varied widely in patient characteristics, back school
length and content, and comparison treatment. The available evidence suggests that back schools do not affect
longterm outcomes of people with back pain. Methods: MEDLINE and PsycLIT databases were searched to identify
randomized trials of cognitive and behavioral treatments for chronic low back pain. Outcome data were extracted
from articles that met the meta-analysis inclusion criteria. Results: The meta-analysis found that cognitive and
behavioral treatments were superior to control conditions after treatment on measures of chronic low back pain, pain
behavior, and disability. Follow-up comparisons of cognitive and behavioral treatments versus control conditions
were not available. This meta-analysis did not find cognitive and behavioral therapies to differ from other active
treatments on specific outcome measures, although only a few studies were available for each measure. Conclusion:
It may be useful to incorporate cognitive-behavioral interventions in primary care settings, but additional research is
needed to evaluate their efficacy in improving specific outcomes.

Watts, RW. & Silagy, CA.:
A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica.
Anaesthesia and Intensive Care 1995 23: 564-9.
Abstracts: The efficacy of epidural corticosteroids in the treatment of sciatica was investigated by meta-analysis of
all randomized controlled trials. Eleven suitable trials of good quality were identified involving a total of 907
patients. The use of epidural (caudal or lumbar) steroid in the short-term (up to 60 days) increased the odds ratio
(OR) of pain relief ( > 75% improvement) to 2.61 (95% CI 1.90-3.77) when compared with placebo. Despite some
variations in trial characteristics there was little evidence of significant heterogeneity (P = 0.07). When the trials
were analysed for near or total relief of pain in the short-term the OR is 2.79 (95% CI 1.92-4.06), for heterogeneity
(P = 0.07). For longterm relief of pain (up to 12 months) the OR is 1.87 (95% CI 1.31-2.68). Efficacy is independent
of the route of injection; for caudal epidural steroid the OR is 3.80 (95% CI 1.36-10.6) and for the lumbar epidural
steroid 2.43 (95% CI 1.77-3.74). Adverse events included dural tap (2.5%), transient headache (2.3%) and a transient
increase in pain (1.9%). There were no reported longterm adverse events. In conclusion we present quantitative evidence
from meta-analysis of pooled data from randomized trials that epidural administration of corticosteroids is effective in the
management of lumbosacral radicular pain.

Patrick, CAJ., Vroomen, de Krom, Marc CTFM., Wilmink, Jan T.,
Kester, Arnold D.M. & Knottnerus, J. Andre.:
Lack of effectiveness of bed rest for sciatica.
N England J Med., 1999 February, 340, 6:11.

Abstracts:
Van den Hoogen, HM., Koes, BW., van Eijk, JT. & Bouter, LM.:
On the accuracy of history, physical examination, and erythrocyte sedimentation rate
in diagnosing low back pain in general practice.
A criteria based review of the literature [see comments].
Spine. 1995 Feb 1; 20, 3: 318-27.
Abstracts: Study design. A criteria-based review of the literature was conducted regarding the accuracy of history,
physical examination, and erythrocyte sedimentation rate in diagnosing low back pain. Objectives. To perform
metaanalysis of the literature regarding signs and symptoms in diagnosing radiculopathy, ankylosing spondylitis, and
vertebral cancer. Summary of background data. Diagnosing low back pain, especially in general practice, depends
largely on history taking, physical examination, and the erythrocyte sedimentation rate. No previous review has
assessed the diagnostic accuracy of signs and symptoms in a systematic way, taking into account the methodological
quality of studies. Methods. The literature was reviewed for relevant studies. Retrieved studies were independently
rated for methodological quality by two reviewers. The reported sensitivity and specificity in the rated studies were
reviewed. Results. Thirty-six eligible studies were retrieved. Major methodological shortcomings were observed,
and only 19 studies scored > or = 55 points (maximal score 100). Not one single test appeared to have high sensitivity
and high specificity in radiculopathy. The combined history and the erythrocyte sedimentation rate had relatively high
diagnostic accuracy in vertebral cancer. Getting out of bed at night and reduced lateral mobility
seemed to be the only moderately accurate items in ankylosing spondylitis. Conclusions. Additional studies that take
into account the shortcomings identified would be needed to produce definite conclusions. Few of the studied signs
and symptoms seemed to be valuable diagnostics for radiculopathy, ankylosing spondylitis, and vertebral cancer.
Reproducibility of signs and symptoms over time might be a valuable diagnostic criterion. However, this was
neglected in almost all studies.

Waddell, G., Feder, G. & Lewis, M.:
Systematic reviews of bed rest and advice to stay active for acute low back pain.
Br J Gen Pract 1997; 47:647-652.
Abstracts: BACKGROUND: In the United Kingdom (UK), 9% of adults consult their doctor annually with back
pain. The treatment recommendations are based on orthopaedic teaching, but the current management is causing
increasing dissatisfaction. Many general practitioners (GPs) are confused about what constitutes effective advice.
AIM: To review all randomized controlled trials of bed rest and of medical advice to stay active for acute back pain.
METHOD: A systematic review based on a search of MEDLINE and EMBASE from 1966 to April 1996 with
complete citation tracking for randomized controlled trials of bed rest or medical advice to stay active and continue
ordinary daily activities. The inclusion criteria were: primary care setting, patients with low back pain of up to 3
months duration, and patient-centred outcomes (rate of recovery from the acute attack, relief of pain, restoration of
function, satisfaction with treatment, days off work and return to work, development of chronic pain and disability,
recurrent attacks, and further health care use). RESULTS: Ten trials of bed rest and eight trials of advice to stay
active were identified. Consistent findings showed that bed rest is not an effective treatment for acute low back pain
but may delay recovery. Advice to stay active and to continue ordinary activities results in a faster return to work,
less chronic disability, and fewer recurrent problems. CONCLUSION: A simple but fundamental change from the
traditional prescription of bed rest to positive advice about staying active could improve clinical outcomes and
reduce the personal and social impact of back pain.

Carragee, EJ.:
Single-level posterolateral arthrodesis, with or without posterior decompression, for the
treatment of isthmic spondylolisthesis in adults. A prospective, randomized study.
J Bone Joint Surg Am, 79(8):1175-80 1997 Aug.
Abstracts: Forty-two neurologically intact adults in whom non-operative treatment of grade-I or grade-II isthmic
spondylolisthesis of the most caudad lumbar segment had failed were entered into a prospective study of the results
of operative treatment. Twenty patients who smoked were managed with a posterolateral arthrodesis with
instrumentation (transpedicular fixation), and twenty-two patients who did not smoke were managed with a
posterolateral arthrodesis without instrumentation. Of the patients who were managed with instrumentation, eight
were randomized to treatment with a decompressive laminectomy and twelve, to treatment without it; in the group
that was managed without instrumentation, the distribution was ten and twelve patients, respectively. The patients
were followed clinically for a mean of 4.5 years (range, 3.5 to six years). Of the eighteen patients who had been
managed with decompression, four had a pseudarthrosis and six had an unsatisfactory result compared with none
and one of the twenty-four who had been managed without decompression (p = 0.02 and p = 0.01, respectively). In
the group of twenty patients (smokers) who had been managed with instrumentation, none of the twelve managed
without decompression had a pseudarthrosis compared with one of the eight managed with decompression (p = 0.2).
In the group of twenty-two patients (non-smokers) who had been managed without instrumentation, none of the
twelve managed without decompression had a pseudarthrosis compared with three of the ten managed with
decompression (p = 0.04). In the group managed with instrumentation, two of the eight who had had decompression
had an unsatisfactory result compared with none of the twelve who had not had decompression. In the group
managed without instrumentation, four of the ten who had had decompression had an unsatisfactory result compared
with one of the twelve who had not had decompression. The addition of decompression to arthrodesis, performed
with or without instrumentation, for the treatment of low-grade isthmic spondylolisthesis in patients who do not
have a serious neurological deficit does not appear to improve the result and may significantly increase the rates of
pseudarthrosis and unsatisfactory results.

Daltroy, LH., Iversen, MD., Larson, MG.et al.
A controlled trial of an educational program to prevent low back injuries.
N England J Med 1997; 337:322-28.
Abstracts: BACKGROUND: Low back injuries are common and costly, accounting for 15 to 25 percent of injuries
covered by workers' compensation and 30 to 40 percent of the payments made under that program. The high costs of
injury, the lack of effective treatment. and the evidence that there are behavioral risk factors have led to widespread
use of employee education programs that teach safe lifting and handling. The effectiveness of those programs,
however, has received little rigorous evaluation. METHODS: We evaluated an educational program designed to
prevent low back injury in a randomized, controlled trial involving about 4000 postal workers. The program, similar
to that in wide use in so-called back schools, was taught by experienced physical therapists. Work units of workers
and supervisors were trained in a two-session back school (three hours of training), followed by three to four
reinforcement sessions over the succeeding few years. Injured subjects (from both the intervention and the control
groups) were randomized a second time to receive either training or no training after their return to work.
RESULTS: Physical therapists trained 2534 postal workers and 134 supervisors. Over 5.5 years of follow-up, 360
workers reported low back injuries, for a rate of 21.2 injuries per 1000 worker-years of risk. The median time off
from work per injury was 14 days (range, 0 to 1717); the median cost was $204 (range, zero to $190,380). After
their return to work, 75 workers were injured again. Our comparison of the intervention and control groups found
that the education program did not reduce the rate of low back injury, the median cost per injury, the time off from
work per injury, the rate of related musculoskeletal injuries, or the rate of repeated injury after return to work; only
the subjects' knowledge of safe behavior was increased by the training. CONCLUSIONS: A large-scale,
randomized, controlled trial of an educational program to prevent work-associated low back injury found no longterm
benefits associated with training.

Grob, D., Humke, T. & Dvorak, J.:
Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis
J Bone Joint Surg Am, 77(7):1036-41 1995 Jul.
Abstracts: We prospectively evaluated the results of decompression of the spine, with and without arthrodesis, for
the treatment of lumbar spinal stenosis without instability in forty-five patients (twenty-one men and twenty-four
women) who had been managed between November 1989 and November 1990. The average age at the time of the
operation was sixty-seven years (range, forty-eight to eighty-seven years). The patients were randomly assigned to
one of three treatment groups (fifteen patients in each group) according to when they were admitted to the hospital.
Group I was treated with decompression with laminotomy and medial facetectomy; Group II, with decompression
and arthrodesis of the most stenotic segment; and Group III, with decompression and arthrodesis of all of the
decompressed vert.

McNeill, TW., Andersson, GB., Schell, B., Sinkora, G., Nelson, J. & Lavender, SA.:
Epidural administration of methylprednisolone and morphine for pain after a spinal operation.
A randomized, prospective, comparative study.
J Bone Joint Surg Am, 77(12):1814-8 1995 Dec.
Abstracts: The results of postoperative epidural administration of saline solution (a placebo), morphine,
methylprednisolone, and a combination of morphine and methylprednisolone for the reduction of pain after an
operation for spinal stenosis or a herniated intervertebral disc were compared in a prospective, randomized blinded
study. Epidural administration of morphine and methylprednisolone--either alone or in combination--significantly
reduced the need for analgesia after an operation for spinal stenosis (p < 0.05) but not after an operation for a
herniated intervertebral disc. Morphine and methylprednisolone did not have an addictive effect on the reduction of
pain. Itching was significantly more common in the patients who had received morphine than in those who had
received the placebo (p = 0.04). Although urinary retention was more frequent after the use of morphine than after
the use of the placebo, thedifference was not significant with the size of the sample that was analyzed (p = 0.25).

Sasso, RC., Williams, JI., Dimasi, N. & Meyer, PR Jr.:
Postoperative drains at the donor sites of iliac-crest bone grafts.
A prospective, randomized study of morbidity at the donor site in patients who had
a traumatic injury of the spine.
J Bone Joint Surg Am, 80(5):631-5 1998 May.
Abstracts: A prospective, randomized study was performed to assess the effectiveness of postoperative closed
suction drainage. One hundred and twelve consecutive procedures involving autologous iliac-crest bone graft were
performed, from December 29, 1992, to July 1, 1993, following a traumatic injury of the spine in 108 patients. Sixty
of the sites from which the bone graft had been obtained were drained with a single large Hemovac device. The
drains were maintained for two to five days postoperatively. The remaining fifty-two incisions were closed without a
drainage device. All patients were evaluated clinically for problems with wound-healing. The incisions were
considered to be healed when they had been asymptomatic for one year. Of eleven patients who had problems with
wound-healing, six had been managed with a drain and five had not. The findings of this study do not support the
routine use of drainage at the donor sites of iliac-crest bone grafts.

Van Poppel, MNM., Koes, BW., van der Ploeg, T., Smid, T. & Bouter, LM.:
Lumbar supports and education for the prevention of low back pain in industry.
JAMA 1998; 279:1789-94.
Abstracts: CONTEXT: Low back pain is a frequent and costly health problem. Prevention of low back pain is
important both for the individual patient and from an economic perspective. OBJECTIVE: To assess the efficacy of
lumbar supports and education in the prevention of low back pain in industry. DESIGN: A randomized controlled
trial with a factorial design. SETTING: The cargo department of an airline company in the Netherlands.
PARTICIPANTS: A total of 312 workers were randomized, of whom 282 were available for the 6-month follow-up.
INTERVENTIONS: Subjects were randomly assigned to 4 groups: (1) education (lifting instructions) and lumbar
support, (2) education, (3) lumbar support, and (4) no intervention. Education consisted of 3 group sessions on
lifting techniques with a total duration of 5 hours. Lumbar supports were recommended to be used during working
hours for 6 months. MAIN OUTCOME MEASURES: Low back pain incidence and sick leave because of back pain
during the 6-month intervention period. RESULTS: Compliance with wearing the lumbar support at least half the
time was 43%. In the 282 subjects for whom data were available, no statistically significant differences in back pain
incidence (48 [36%] of 134 with lumbar support vs 51 [34%] of 148 without, P=.81) or in sick leave because of low
back pain (mean, 0.4 days per month with lumbar support vs 0.4 days without, P=.52) were found among the
intervention groups. In a subgroup of subjects with low back pain at baseline, lumbar supports reduced the number
of days with low back pain per month (median, 1.2 vs 6.5 days per month; P=.03). CONCLUSIONS: Overall,
lumbar supports or education did not lead to a reduction in low back pain incidence or sick leave. The results of the
subgroup analysis need to be confirmed by future research. Based on our results, the use of education or lumbar
supports cannot be recommended in the prevention of low back pain in industry.

Vroomen, de Krom, Marc CTFM., Wilmink, Jan T., Kester, Arnold D.M. & Knottnerus, J. Andre.:
Lack of effectiveness of bed rest for sciatica.
N Engl J Med, 340(6):418-23, 1999 Feb 11.
Abstracts: BACKGROUND AND METHODS: Bed rest is widely advocated for sciatica, but its effectiveness has
not been established. To study the effectiveness of bed rest in patients with a lumbosacral radicular syndrome of
sufficient severity to justify treatment with bed rest for two weeks, we randomly assigned 183 subjects to either bed
rest or watchful waiting for this period. The primary outcome measures were the investigator's and patient's global
assessments of improvement after 2 and 12 weeks, and the secondary outcome measures were changes in functional
status and in pain scores (after 2, 3, and 12 weeks), absenteeism from work, and the need for surgical intervention.
Neither the investigators who assessed the outcomes nor those involved in data entry and analysis were aware of the
patients' treatment assignments. RESULTS: After two weeks, 64 of the 92 patients in the bed-rest group (70 percent) reported improvement, as compared with 59 of the 91 patients in the control (watchful-waiting) group (65 percent) (adjusted odds ratio for improvement in the bed-rest group, 1.2; 95 percent confidence interval, 0.6 to 2.3). After 12 weeks, 87 percent of the patients in both groups reported improvement. The results of assessments of the intensity of pain, the bothersomeness of symptoms, and functional status revealed no significant differences between the two groups. The extent of absenteeism from work and rates of surgical intervention were similar in the two groups. CONCLUSIONS: Among patients with symptoms and signs of a lumbosacral radicular syndrome, bed rest is not a more effective therapy than watchful waiting.

Cintura pélvica
 

Fourie, JA., Lief, EMP. & Dunne, TT.:
Pillow positioning facilitates independent bridging for bedpan use in pelvic fractures.
S Afr J Physiother 1992, 48, 3:41-44. [Abstract]
Abstracts: The idea of giving a patient with fractures of the pelvis a mechanical advantage, by placing pillows under
his/her back in order to make bridging for the bedpan easier, was tested in this clinical trial. Twenty-nine subjects
were entered by block randomisation into the experimental group and twenty-nine into the control group. The
number of days from entry into the trial until independent bridging was noted. Independent bridging is defined as the
patient being able to lift high enough to slide a conventional stainless steel bedpan under the buttocks. Results show
that there is a significant difference in time to bridging (gamma = 0,602, p = 0,0027) in favour of the experimental
group Other variables studied appear to marginally favour the control rather than the experimental group, thus
suggesting that the pillow method could be used safely and effectively in the treatment of patients who have
sustained a range of pelvic fractures.

Matta, JM. & Siebenrock, KA.: Does indomethacin reduce heterotopic bone formation
after operations for acetabular fractures? A prospective randomised study.
J Bone Joint Surg. 1997, 79-B, 6:959-63.
Abstracts: We have studied prospectively the effect of indomethacin on the development of heterotopic ossification
(HO) after the internal fixation of acetabular fractures. After operation 107 patients randomly received either a six week course of indomethacin or no treatment against HO. Plain radiographs of 101 patients at a mean of 7.9 months
after surgery showed HO in 47.4% of the 57 patients who received indomethacin and in 56.8% of the 44 who did
not. This difference was not statistically significant. Heterotopic ossification of Brooker class II or more was seen in
four patients (7%) with prophylaxis and in one without (p = 0.51). Measurements of the volume of HO on 3-D CT
reconstructions showed a median value of 1.5 cm3 in patients with indomethacin and 4.0 cm3 in those without (p =
0.28). When only the 57 patients in whom the operation was carried out through either a Kocher-Langenbeck or an
extended iliofemoral approach were included the indomethacin group showed a median volume of 1.7 cm3
compared with 3.6 cm3. On plain radiographs Brooker class II or above was seen in 9.4% of the patients receiving
indomethacin and in 4.8% of those who did not. Indomethacin was therefore not effective in preventing ectopic bone
formation after surgery for acetabular fractures. There was a significant association of male gender with volume of
HO using a non-parametric analysis of variance.

Moore, KD., Goss, K. & Anglen, JO.:
Indomethacin versus radiation therapy for prophylaxis against
heterotopic ossification in acetabular fractures:
a randomised, prospective study.
J Bone Joint Surg. 1998, 80- B, 2:259-63.
Abstracts: We report a prospective, randomised, blinded clinical comparison of the use of indomethacin or radiation
therapy for the prevention of heterotopic ossification (HO) in 75 adults who had open reduction and internal fixation
of acetabular fractures through either a Kocher-Langenbeck, a combined ilioinguinal and Kocher-Langenbeck, or an
extended iliofemoral approach. Indomethacin, 25 mg, was given three times daily for six weeks. Radiation with 800
cGy was delivered within three days of operation. Plain radiographs were reviewed and given Brooker classification
scores by three independent observers who were unaware of the method of prophylaxis. One patient died from
unrelated causes and two were lost to follow-up, leaving 72, 33 in the radiation group and 39 in the indomethacin
group, available for evaluation at a mean of 12 months (6 to 48). There was no significant difference in the two
groups in terms of age, gender, injury severity score, estimated blood loss, delay to surgery, head injury, presence of
femoral head dislocation, or operating time, and no complications due to either method of treatment. The final extent
of HO was already present by six weeks in all patients who were followed up. Three patients in the radiation group
and five who received indomethacin developed HO of Brooker grade III. Two patients in the indomethacin group
developed Brooker IV changes; both had failed to receive proper doses of the drug. Cochran-Armitage analysis
showed no significant difference between the two treatment groups as regards the formation of HO. Indomethacin
and single-dose radiation therapy are both safe and effective for the prevention of HO after operation for acetabular
fractures. Radiation therapy is, however, approximately 200 times more expensive than indomethacin therapy at our
institution and has other risks.

Montgomery, KD., Potter, HG. & Helfet, DL.:
Magnetic resonance venography to evaluate the deep venous
system of the pelvis in patients who have an acetabular fracture.
J Bone Joint Surg 1995, 77-A, 11 :1639-49.
Abstracts: We performed a prospective, blinded study to assess and compare the values of preoperative contrast
venography and magnetic resonance venography in the detection of deep venous thrombosis in the thigh and pelvis
of forty-five consecutive patients who had a displaced acetabular fracture. The magnetic resonance venography and
contrast venography were performed an average of seven days (range, one to twenty-nine days) after the injury.
Twenty-four asymptomatic thrombi were identified with magnetic resonance venography in fifteen (33 percent) of
the patients. Four of the thrombi were in the superficial femoral vein, nine were in the common femoral vein, one
was in the external iliac vein, seven were in the internal iliac vein, and three were in the common iliac vein. Ten (42
percent) of the twenty-four thrombi were confirmed with contrast venography; nine of them were located in the
thigh. The remaining fourteen thrombi (58 percent) that had been noted on magnetic resonance venography could
not be seen with contrast venography because they were located either in the deep pelvic veins or in the uninjured
extremity. The thrombi in the internal iliac vein were identified only with magnetic resonance venography. Twelve
of the fifteen patients who had thrombi had a filter placed in the inferior vena cava preoperatively. In eight of these
patients, the filter was placed because of the findings of magnetic resonance venography alone. Magnetic resonance
venography resulted in a change in the therapeutic management of ten (22 per cent) of the forty-five patients. There
were no pulmonary emboli. We concluded that magnetic resonance venography is superior to contrast venography
for the preoperative evaluation of proximal deep venous thrombosis in patients who have an acetabular fracture.
Magnetic resonance venography is non-invasive, does not require the use of contrast medium, images the proximal
aspects of both lower extremities simultaneously, and, most importantly, allows for the identification of deep venous
thrombosis in the pelvis.

Noordeen, MH; Taylor, BA; Briggs, TW. & Lavy, CB.:
Pin placement in pelvic external fixation.
Injury 1993, 24, 9:581-4.
Abstracts: Early external fixation of major pelvic fractures reduces haemorrhage and mortality. The best site and
method for pin placement remains unresolved. The superior iliac crest is biomechanically disadvantageous and
hinders access to the abdomen. Low pin placement between the anterior iliac spines has been proposed as a better
solution. A case-controlled study was performed on cadavers using a jig designed to place external fixator pins
accurately in the pelvis; the study tested the safety of pin placement and the mechanical strength of the two
placement sites. The results showed that pins could be placed safely using this method and that low placement in
cadaveric bone is as strong as that of the conventional placement.
 

[Cadera]
 

Alho, A.:
Concurrent ipsilateral fractures of the hip and femoral shaft: a meta-analysis of 659 cases.
Acta Orthop Scand Feb 1996, 67, 1:19-28.
Abstracts: 659 cases of concurrent' ipsilateral fractures in the hip and femoral shaft reported in 59 studies were
analyzed. The causes were a road traffic accident in 78% and other types of high-energy traumas in 13% of the
patients. This injury combination was rare in children. The median age was 34 years. 78% of the patients were men.
One-third had multiple injuries' one-half had inJuries of the ipsilateral knee and one-half had other lower limb
injuries. The femoral neck fractures were most often basilar and the reported rate of avascular necrosis was 3%. The
trochanteric fractures were intertrochanteric transverse' and seldom comminuted. The important factors in reducing
morbidity were an early diagnosis of all inJuries and efficient treatment of the shaft fractures. Locked intramedullary
nails yielded results which were superior to combinations of plates or unlocked nails and separate hip screws.
Reconstruction nails (cephalomedullary nails) gave results equal to those of customary locked nails and separate hip
screws. The rate of healing of the hip fracture was over 99%' the treatment of the shaft fracture being of main
importance for the outcome.

Baudoin, C., Fardellone, P. & Sebert, JL.:
Effect of sex and age on the ratio of cervical to trochanteric hip fracture.
A meta-analysis of 16 reports on 36,451 cases.
Acta Orthop Scand, 64(6):647-53 1993 Dec.
Abstracts: The aim of this study was to evaluate the burden of hip fractures, which occurred in the French region of
Picardie, in 1992, among 1103 women and 356 men, whether the fractures occurred at home or in a community (i.e.,
patients who depended on a collective service). The data are part of the PICAROS study, which was designed to
assess prospectively the outcome of patients as judged by clinical, economical, and quality of life factors. Patients
and/or proxies were questioned during the 2nd or 3rd week following the fracture, and again at 3, 6, 12, and 24
months after the fracture. The survey was conducted by home interview. Recruitment criteria were: 1) all patients
with a hip fracture as defined by the International Classification of Disease (ICD); 2) 20 years of age and over; 3)
admitted to one of the 34 surgical units from the region, public and private, and had an operation or not. Patients
with metastatic or myelomatous fractures or fractures on prothesis device were not included. For the present
analysis, patients under 50 years of age were excluded. Among people aged 50 years and over, 3% of the general
population lived in a community; 32% of hip fractures were from a community. Patients in a community, aged 60-
69, had 15 times more risk of having a hip fracture than subjects of the same age at home. The excess risk decreased
with age and stabilized over 85 years of age at two to threefold. During the 24 month follow-up, 394 women and
173 men died. Among those surviving, 87% were interviewed at 2 years. We analysed seven classes of
complications, according to the ICD: (1) pressure sores and blisters; (2) pulmonary infections; (3) urinary infections;
(4) surgical complications; (5) orthopedic complications; (6) thrombosis and embolisms; and (7) secondary hip
fractures. Patients coming from a community had a higher risk of mortality, pressure sores, surgical complications,
and pulmonary and urinary infections. From an economical perspective, the institutionalized population would seem
to be a profitable target for the prevention of fractures and their complications.

Callaghan, JJ.:
Total hip arthroplasty.
Clinical perspective.
Clin Orthop. 1992 Mar; 276: 33-40.
Abstracts: The orthopedic surgeon performing total hip arthroplasty (THA) today has many choices in the selection
of the implant and mode of fixation. The clinical perspective, obtained from the available literature, is presented to
facilitate these decisions by reviewing results of cemented and cementless primary and revision THA.

Law, MR. & Hackshaw, AK.:
A meta-analysis of cigarette smoking, bone mineral density and risk of hip
fracture: recognition of a major effect.
BMJ 4 Oct 1997, 315, 7112:841-6.
Abstracts: Objetive: To determine the magnitude and importance of the relation between smoking, bone mineral
density, and risk of hip fracture according to age. Design: Meta-analysis of 29 published cross sectional studies
reporting the difference in bone density in 2156 smokers and 9705 non-smokers according to age, and of 19 cohort
and case-control studies recording 3889 hip fractures reporting risk in smokers relative to non-smokers. Results: In
premenopausal women bone density was similar in smokers and non-smokers. Postmenopausal bone loss was
greater in current smokers than non-smokers, bone density diminishing by about an additional 2% for every 10 year
increase in age, with difference of 6% at age 80. In current smokers relative to non-smokers the risk of hip fracture
was similar at age 50 but greater thereafter by an estimated 17% at age 60, 41% at 70, 71% at 80, and 108% at 90.
These estimates of relative risk by age, derived directly from a regression analysis of the studies of smoking and hip
fracture, were close to estimates using the difference in bone density between smokers and non-smokers and the
association between bone density and risk of hip fracture. The estimated cumulative risk of hip fracture in women in
England was 19% in smokers and 12% in non-smokers to age 85; 37% and 22% to age 90. Among all women, one
hip fracture in eight is attributable to smoking. Limited data in men suggest a similar proportionate effect of
smoking as in women. The association was not explained by smokers being thinner, younger at menopause, and
exercising less nor by actions of smoking on oestrogen, but smoking may have a direct action on bone. Conclusions:
Hip fracture in old age is a major adverse effect of smoking after the menopause. The cumulative excess bone loss
over decades is substantial, increasing the lifetime risk of hip fracture by about half.

Lu-Yao GL; Keller RB; Littenberg B; Wennberg JE.:
Outcomes after displaced fractures of the femoral neck.
A meta-analysis of one hundred and six published reports.
J Bone Joint Surg Am, 76(1):15-25 1994 Jan.
Abstracts: Methods of meta-analysis, a technique for the combination of data from multiple sources, were applied
to analyze 106 reports of the treatment of displaced fractures of the femoral neck. Two years or less after primary
internal fixation of a displaced fracture of the femoral neck, a non-union had developed in 33 per cent of the patients
and avascular necrosis, in 16 per cent. The rate of performance of a second operation within two years ranged from
20 to 36 per cent after internal fixation and from 6 to 18 per cent after hemiarthroplasty (relative risk, 2.6; 95 per
cent confidence interval, 1.4 to 4.6). Conversion to an arthroplasty was the most common reoperation after internal
fixation and accounted for about two-thirds of these procedures. The remaining one-third of the reoperations were
for removal of the implant or revision of the internal fixation. For the patients who had had a hemiarthroplasty, the
most common reoperations were conversion to a total hip replacement, removal or revision of the prosthesis, and
d´ebridement of the wound. Although we observed an increase in the rate of mortality at thirty days after primary
hemiarthroplasty compared with that after primary internal fixation, the difference was not significant (p = 0.22) and
did not persist beyond three months. The absolute difference in perioperative mortality between the two groups was
small. An anterior operative approach for arthroplasty consistently was associated with a lower rate of mortality at
two months than was a posterior approach. Some reports showed promising results after total hip replacement for
displaced fractures of the femoral neck; however, randomized clinical trials are still needed to establish the value of
this treatment.

Michelson, JD. & Riley, LH. Jr:
Considerations in the comparison of cemented and cementless total hip prostheses.
J Arthroplasty 1989 Dec; 4, 4: 327-34.
Abstracts: Based on conservative models of the revision rates for cemented and uncemented hip arthroplasties, the
required number of patients for a study to show significant uncemented superiority was determined using standard
statistical techniques. A review of the literature was done to ascertain the revision rates for cemented total hip
arthroplasties. Patients with osteoarthritis who were older than 50 years had an average revision rate of 1% per year,
while those younger than 50 years had revision rates in excess of 2% per year. Specific conditions of the hip were
also associated with increased failure rates, most notably the implantation of a revision arthroplasty for a previously
failed total hip arthroplasty. Assuming that the uncemented hip had a long-term revision rate of 0.5% per year and
an early lack of biologic fixation in 1% of patients, it was found that a 5-year study would have to include at least
2,800 patients (1,400 in each group) if the study population had a cemented failure rate of 1% per year and a total of
230 patients in those having a cemented failure rate of 2% per year. The patients needed for a 10-year evaluation
would be 700 and less than 100, respectively. Altering the long- or short-term revision rate for uncemented total hip
arthroplasty had relatively little effect on the study size. This analysis indicates that a comparison study would be
best done in patients who have high failure rates with cemented total hip arthroplasties. Multicenter trials involving
younger patients or those undergoing revision surgery are ideally suited for such an investigation.

Murray DW; Britton AR; Bulstrode CJ.:
Thromboprophylaxis and death after total hip replacement.
J Bone Joint Surg Br, 78(6):863-70 1996 Nov.
Abstracts: The recommendation that patients having a total hip replacement should receive pharmacological
thromboprophylaxis is based on the belief that fatal pulmonary embolism is common, and that prophylaxis will
decrease the death rate. To investigate these assumptions we performed a meta-analysis of all studies on hip
replacement which included information about death or fatal pulmonary embolism. A total of 130 000 patients was
included. The studies were so varied in content and quality that the results of our analysis must be interpreted with
some caution. The fatal pulmonary embolism rate was 0.1% to 0.2% even in patients who received no prophylaxis.
This is an order of magnitude lower than that which is generally quoted, and therefore the potential benefit of
prophylaxis is small and may not justify the risks. To balance the risks and benefits we must consider the overall
death rate. This was 0.3% to 0.4%, and neither heparin nor any other prophylactic agent caused a significant
decrease. Our study demonstrates that there is not enough evidence in the literature to conclude that any form of
pharmacological thromboprophylaxis decreases the death rate after total hip replacement. For this reason guidelines
which recommend their routine use to prevent death after hip replacement are not justified.

Parker, MJ. & Pryor, GA.:
Gamma versus DHS nailing for extracapsular femoral fractures.
Meta-analysis of ten randomised trials.
Int Orthop. 1996; 20, 3: 163-8.
Abstracts: A meta-analysis has been carried out of all published randomised trials which compare the gamma with
the DHS nail, giving in a total of 1794 patients with extracapsular femoral fractures. Results showed that the
Gamma nail had a significantly increased risk of fracture of the femoral shaft and an increased reoperation rate.
There was no difference in the lag screw cut-out rates, incidence of wound infection or length of stay in hospital.
The gamma nail cannot be recommended for routine use in trochanteric fractures until the problem of femoral shaft
fracture is resolved.

Parker, MJ. & Blundell, C.:
Choice of implant for internal fixation of femoral neck fractures.
Meta-analysis of 25 randomised trials including 4.925 patients.
Acta Orthop Scand. 1998 Apr, 69, 2: 138-43.
Abstracts: We reviewed all randomised trials comparing different implants for treating intracapsular fractures of
the hip and, where possible, the data were combined. 25 randomised trials were identified involving 4,925 patients.
Screws appeared to be superior to pins. It was not possible to determine the optimum number or type of screws. No
advantage was shown for an implant with a side-plate.

Sorenson, MJ. & Blundell, C.:
Anesthetic Techniques during Surgical Repair of Femoral Neck Fractures. A Meta-analysis.
Anesthesiology; 1992 Dec, 77, 6: 1095-1104.
Abstracts: Fracture of the hip typically occurs in the older women. These patients usually have serious
accompanying chronic illnesses. There is a diference of opinion as to the choice of regional versus general
anesthesia for surgery in these patients. This meta-analysis compared survival of patients with traumatic femoral
neck fractures undergoing operative repair during regional and general anesthesia from peer reviewed journals.
Thirteen randomized controlled trials were found. Besides 1-month mortality, variables used were estimated
operative blood loss and the incidence of deep venous thrombosis. For dichotomous outcomes, two effect measures
were calculated: the difference in probabilities and the odds ratio. For blood loss, a continuous variable, the effect
measures was the mean difference blood loss. A random-effects Bayesian meta-analysis was used to combine study
data, estimate parameters and create 95 % confidence intervals. Only the incidence of deep venous thrombosis was
crearly greater for patients receiving general anesthesia, being 31 porcentage points higher than for patients
receiving regional anesthesia. By the odds ratio, deep venous thrombosis was almost four times more likely
following general anesthesia. There was no difference in estimated operative blood loss. By probability difference,
mortality was a non-significant 2.7 percentage points less following regional anesthesia. By the odds ratio effect
measures, death was 1.5 times more likely following general anesthesia, but the lower bound of the 95 % confidence
interval was close to 1. Meta-analysis does not allow a conclusion that important differences in mortality exist
between regional and general anesthesia for traumatic hip fractures surgery.

Yahiro MA; Gantenberg JB; Nelson R; Lu HT; Mishra NK.:
Comparison of the results of cemented, porous ingrowth, and threaded acetabular cup fixation.
A meta-analysis of the orthopaedic literature.
JArthroplasty, 10(3):339-50 1995 Jun.
Abstracts: A meta-analysis of the orthopaedic literature was performed to evaluate the clinical performance of
cementless, threaded acetabular cups. The hypothesis for the study was that the clinical performance of the
cementless, threaded acetabular cup is equivalent to that of the cemented and porous-ingrowth acetabular cups.
Ninety-five articles were included in the study. There were 1,269 cases in the threaded cup group, 1,979 in the
porous control group, and 10,230 in the cemented control group. The primary outcome variable tested was the rate
of aseptic loosening of the acetabular components as measured by the revision rates following the index total hip
arthroplasty procedure. Other measures of acetabular component loosening that were analyzed included clinical
rating scores, pain scores, frequency of radiolucencies according to location and size, frequency of radiolucencies as
a separately defined outcome variable, progressive radiolucencies, and component migration. The threaded cup
group was found to have a significantly higher rate of revision, clinical and pain score failures, progressive
radiolucencies and migrations when compared with the cemented and porous control groups (P < .05). Despite the
many limitations of meta-analyses and the poor state of the orthopaedic literature database, this study provides a
reasonable comparison of the clinical performance of threaded acetabular cups with that of cemented and porous ingrowth acetabular cups.

Yrjonen, T.:
Long-term prognosis of Legg-Calve-Perthes disease: a meta-analysis.
J Pediatr Orthop B. 1999  Jul, 8, 3: 169-72.
Abstracts: In the literature, long-term prognosis of Legg-Calve-Perthes disease (LCPD) means prognosis for
secondary osteoarthritis of the hip joint or leg-length inequality and its consequences. Most studies show results
after conservative treatment. The long-term natural history of LCPD is not known. In spite of deformity, most
patients do well in early adulthood. Radiographic and clinical osteoarthritis is increased in 20-year to 40-year
follow-ups and degenerative joint disease develops in the majority of patients by the sixth or seventh decade of life.
The reported average shortening of the affected leg has usually been 1 to 1.5 cm. There are no thorough long-term
reports on low back pain after LCPD. The only evidence-based factors that are of prognostic importance in the longterm
are age of the patient at the onset of the disease and shape of the femoral head at skeletal maturity.

Alho, A.:
Concurrent ipsilateral fractures of the hip and shaft of the femur.
A systematic review of 722 cases.
Ann Chir Gynaecol 1997, 86, 4:326-36.
Abstracts: BACKGROUND AND AIMS: Ipsilateral fracture of the hip and femoral shaft is encountered in
high energy trauma, and warrants special diagnostic and therapeutic considerations, which are not available in any single
report. Therefore, a meta-analysis was performed. MATERIAL AND METHODS: Seven hundred and twenty-two
cases of concurrent, ipsilateral fractures in the hip and femoral shaft reported in 65 publications were reviewed. This
high-energy injury combination was rare in children, the median age of the patients being 34 years (range 3-76
years). 78% of them were men, 44% were multiply injured. Concurrent hip fractures were reported in 0.8 to 8.6% of
all femoral shaft fractures. RESULTS: The trauma force was found to cause buckling of the femur and shearing of
the femoral neck. Hip fractures, divided into 5 subtypes, had the following distributions: subcapital-2%,
midcervical-21%, basicervical-39%, pertrochanteric-14% and intertrochanteric-24%. The diagnosis of the hip
fracture was delayed in 30% of the cases, but it healed in 99% with most operative methods with no deep infections.
The average rate of avascular necrosis of the femoral head was 5.1%. Plate fixation of the shaft fracture was
complicated by deep infection in 6.1%, by non-union in 9.8% and yielded a poor outcome in 11.0% of the cases.
The respective figures for unlocked intramedullary nailing were 2.7%, 2.7% and 6.8% and for locked nailing 0%,
0% and 0%, respectively. Fixation of the hip fracture was bound with more complications (reoperations and
malunions) in combination with nailing than plate fixation. CONCLUSIONS: Early diagnosis of all injuries and
operative treatment of all fracture components are the key factors in reducing complications and improving the
outcome in ipsilateral hip and shaft fractures. Locked nails and hip screws yield improved results compared with
plates and unlocked nails combined with hip screws. Cephalo-medullary nails have yielded results similar to the
first-generation locked nails.

Towheed, TE. & Hochberg, MC.:
A systematic review of randomized controlled trials of pharmacological
therapy in osteoarthritis of the hip.
J Rheumatol. 1997 Feb; 24, 2: 349-57.
Abstracts: OBJECTIVE: To systematically review all randomized controlled trials (RCT) of pharmacological
therapy in osteoarthritis (OA) of the hip. To determine which nonsteroidal antiinflammatory drug (NSAID) is the
most effective, and which NSAID is the most toxic. METHODS: A MEDLINE search was used to identify RCT of
pharmacological therapy in patients with OA of the hip published between 1966 and August 1994. Qualitative
assessments were performed using a quality scoring system designed for NSAID trials in rheumatoid arthritis. Both
the design and analysis aspects of the trials were evaluated, each aspect rated on a scale of 0 to 8. A quantitative
method, which calculates the ratio of improvement produced by one NSAID to that produced by another, was used
to rate the relative efficacy of different NSAID with respect to pain relief. Toxicity comparisons were made
according to the authors' findings. RESULTS: 43 RCT were identified, and of these, 39 evaluated NSAID while 4
evaluated only analgesics. The median design and analysis scores were 2 and 4, respectively, 6 NSAID were
included in at least 5 trials; of these, indomethacin was rated more effective in 5 of its 7 comparisons, but more toxic
in 7 of 12 comparisons. Only 5 of the 29 (17%) NSAID comparisons found statistically significant differences in
efficacy. CONCLUSION: NSAID trials in patients with OA of the hip appear to be weakened by the lack of
standardization of case definition of OA, and also by the lack of standardization of outcome assessments. No
recommendations for the choice of specific NSAID therapy in hip OA can be offered based on this analysis.

Anders RL; Ornellas EM.:
Acute management of patients with hip fracture. A research literature review.
Orthop Nurs; 16, 2: 31-46, Mar-Apr. 1997.
Abstracts: PURPOSE: To provide the orthopaedic nurse a summary of the significant research concerning the
management of patients with a fractured hip. DESIGN: Meta-Analysis. SAMPLE: 135 articles reviewed for possible
inclusion' 57 original research reports and publications are reported. METHODS: For the years 1985 to March 1996
Medline' MEDLARS' and CINAHL data bases were searched. Twenty-seven search terms were used' including hip
fractured)' orthopedic standards' and length of stay. MAIN RESEARCH CLASSIFICATIONS: Preoperative'
Operative and Postoperative. Studies arranged by author' outcomes' focus' data source and year' sample' and
findings. FINDINGS: Research reports were found concerning: preoperative care including the use of MRI'
predictors of complications and transfusion needs' and impact of skin traction on pain; operative studies including
spinal anesthesia and oxygen saturation rates' use of blankets to keep patient warm' prophylactic antibiotic use' and
impact of delaying surgery; and postoperative reports including the incidence of DVT' nutritional status'
cauterization' management protocols' morbidity and mortality risks' length of stay' functional status' and ambulation.
CONCLUSION: The scientific merit of each study was not evaluated in depth. With some degree of comfort the
review did find one study or several studies to support the findings presented. IMPLICATIONS FOR NURSING
RESEARCH: Current research concerning the impact of pressure sores' incontinence' management of falls risk' and
the impact the fear of falling on postinjury patients are just a few of the topics not adequately addressed.

Buciuto R; Uhlin B; Hammerby S; Hammer R.:
RAB-plate vs Richards CHS plate for unstable trochanteric hip fractures.
A randomized study of 233 patients with 1-year follow-up.
Acta Orthop Scand, 69(1):25-8 1998 Feb.
Abstracts: We prospectively randomized 233 patients with unstable trochanteric hip fractures for treatment with a
120 degrees fixed angle blade-plate having a buttress rod (group A, n 111) or a 135 degrees compression hip screw
(group B, n 122). The minimum follow-up time was 1 year. The ratio of technical failure was 9% in group A and
19% in group B (p= 0.06). 79 (87%) fractures in group A and 65 (68%) fractures in group B healed without any
complication (p = 0.003). Malunion occurred in 2 cases in group A and in 15 cases in group B (p = 0.002).

Hardy DC; Descamps PY; Krallis P; Fabeck L; Smets P; Bertens CL; Delince PE.:
Use of an intramedullary hip-screw compared with a compression hip-screw with a plate
for intertrochanteric femoral fractures.
A prospective, randomized study of one hundred patients.
J Bone Joint Surg Am, 80(5):618-30 1998 May.
Abstracts: One hundred elderly patients who had an intertrochanteric femoral fracture were randomized to
treatment with a compression hip-screw with a plate (fifty patients) or a new intramedullary device, the
intramedullary hip-screw (fifty patients). All patients were followed prospectively for one year or until death. A
detailed assessment of the functional status and the plain radiographs of the hip was performed one, three, six, and
twelve months postoperatively. The two treatment groups were strictly comparable. The operative time needed to
insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw
with the plate (p = 0.02), but use of the intramedullary hip-screw was associated with less estimated intraoperative
blood loss (p = 0.011). The prevalence of perioperative complications, such as bronchopneumonia, cardiac failure,
and urinary tract infection, was comparable in the two treatment groups. There were one intraoperative fracture of
the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the
intramedullary hip-screw. One patient had pulling-out of the compression hip-screw on the seventh postoperative
day. Four patients had a trochanteric wound hematoma, without infection, after insertion of an intramedullary hipscrew.
All but one of the fractures healed. The one non-union, which was in a patient who had a compression hipscrew,
was treated with a hemiarthroplasty. The mortality rate was similar in the two treatment groups. The patients
who had an intramedullary hip-screw had, on the average, significantly better mobility at one (p < 0.0001) and three
months (p = 0.0013) postoperatively. This difference was no longer seen at six and twelve months, although the
patients who had an intramedullary hip-screw still had significantly better walking ability outside the home at those
time-periods (p = 0.05). The compression hip-screw was removed from two patients because of pain in the midportion
of the thigh, which had begun after consolidation of the fracture. Fourteen patients who had an
intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at twelve months postoperatively.
Cortical hypertrophy was significantly related to the use of two interlocking screws (p = 0.02). Six of these patients
also had pain in the mid-portion of the thigh, and the nail had been locked with two screws in five of them. Three of
the six patients had the hardware removed because of the pain, and the symptoms resolved. A seventh patient had
pain without cortical hypertrophy. The intramedullary hip-screw device was associated with significantly less
sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh (p = 0.012 and 0.019,
respectively); these differences were more pronounced when the unstable fractures in the two treatment groups were
compared (p < 0.001).

Koo KH; Kim R; Ko GH; Song HR; Jeong ST; Cho SH.:
Preventing collapse in early osteonecrosis of the
femoral head. A randomised clinical trial of core decompression [see comments]
J Bone Joint Surg Br, 77(6):870-4 1995 Nov.
Abstracts: We performed a randomised trial on 37 hips (33 patients) with early-stage osteonecrosis (ON). After the
initial clinical evaluation, including plain radiography and MRI, 18 hips were randomly assigned to a core decompression group and 19 to a conservatively-treated group. All the patients were regularly followed up by
clinical evaluation, plain radiography and MRI at intervals of three months. Hip pain was relieved in nine out of ten
initially symptomatic hips in the core-decompression group but persisted in three out of four initially painful hips in
the conservatively-treated group at the second assessment (p < 0.05). At a minimum follow-up of 24 months, 14 of
the 18 core-decompressed hips (78%) and 15 of the 19 non-operated hips (79%) developed collapse of the femoral
head. By survival analysis, there was no significant difference in the time to collapse between the two groups (logrank test p = 0.79). Core decompression may be effective tin symptomatic relief, but is of no greater value than
conservative management in preventing collapse in early osteonecrosis of the femoral head.

Laupacis A; Rorabeck C; Bourne R; Tugwell P; Bullas R; Rankin R; Vellet AD; Feeny D; Wong C.:
The frequency of venous thrombosis in cemented and non-cemented hip arthroplasty.
J Bone Joint Surg Br, 78(2):210-2 1996 Mar.
Abstracts: We randomised 250 patients undergoing unilateral, elective hip arthroplasty for osteoarthritis to receive
either a cemented or a non-cemented Mallory Head prosthesis. Aspirin was used as prophylaxis against
thromboembolism during the first half of the study and adjusted-dose warfarin during the second half.
Postoperatively, all patients were asked to have bilateral venography and 80% agreed. All were evaluated clinically
for pulmonary embolism. There was no difference in the frequency of deep-venous thrombosis between the two
groups (50% cemented nu 47% non-cemented, p = 0.73; 95% CI of the difference -13.6% to 19.3%). Three of the 64 patients (5%) in whom venography had demonstrated isolated distal thrombi developed pulmonary emboli.

Persson PE; Sodemann B; Nilsson OS.:
Preventive effects of ibuprofen on periarticular heterotopic ossification after total hip arthroplasty.
A randomized double-blind prospective study of treatment time.
Acta Orthop Scand, 69(2):111-5 1998 Apr.
Abstracts: We determined the efficacy and the minimum treatment time necessary for prophylaxis with
nonsteroidal anti-inflammatory drugs (NSAIDs) for periarticular heterotopic ossification (HO) after total hip
arthroplasty (THA). Using a double-blind placebo controlled design, 144 patients operated on with total hip
arthroplasty for primary arthrosis were treated postoperatively with (1) ibuprofen for 3 weeks, (2) ibuprofen for 1
week and placebo for the next 2 weeks or (3) placebo for 3 weeks. Radiographic occurrence of periarticular
heterotopic ossification and complications of the treatment were recorded for the first year. Both ibuprofen-treated
groups showed significantly less HO than the placebo-treated group. There was no difference in HO between the
patients treated for 8 or 21 days postoperatively. Both 8 and 21 days of treatment with ibuprofen following THA
effectively prevents clinically significant degrees of HO. No serious short-term complications of the treatment were
noted.
 

[Muslo]
 
 

Littenberg, B., Weinstein, LP., McCarren, M., Mead, T., Swiontkowski, MF., Rudicel, SA. & Heck, D.:
Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment.
J Bone Joint Surg Am. 1998 Feb, 80, 2: 174-83.
Abstract: We reviewed the literature to determine the clinical outcomes of the treatment of closed fractures of the
tibial shaft with immobilization in a cast, open reduction with internal fixation, or fixation with an intramedullary
rod. We reviewed 2372 reports of comparative trials and uncontrolled studies of series of patients published between
1966 and 1993. Nineteen reports, involving six controlled trials and twenty-seven groups of patients, met our
inclusion criteria. A structured questionnaire was used to assess the quality of the literature in terms of the
experimental design and the method of assessment of outcome. Outcomes from controlled trials were summarized
with odds ratios and risk differences, and outcomes from case series were summarized by the medians of the
reported results. The studies that were reviewed generally had few subjects and were poorly designed. The
comparative trials showed treatment with a cast to be associated with a lower rate of superficial infection than open
reduction and internal fixation (mean difference, -5.81 per cent; p = 0.02) and open reduction and internal fixation to
be associated with a higher rate of union by twenty weeks than treatment with a cast (mean difference, -18.07 per
cent; p = 0.008). There were no other significant associations. There were insufficient data for us to evaluate any
aspect of functional status, level of pain, or other patient-reported outcomes of any of the methods of treatment. The
results of the present review suggest that the data from the published literature are inadequate for decision-making
with regard to the treatment of closed fractures of the tibia.

McLaren, A.C. , Roth, J.H. & Wright, C.:
Intramedullary Rod Fixation of Femoral Shaft Fractures:
Comparison of Open and Closed Insertion Techniques.
Canadian Journal Surgery - CJS, 33, 4: 286-90, August 1990.
Abstract: Meta-analysis of published series of intramedullary rod fixation in fractured femurs revealed significantly
higher union rates, lower deep infection rates and a betterrange of knee motion when closed rather than open
techniques of insertion were used. A separate retrospective review of 58 femoral fractures at one hospitalshowed
outcomes consistent with those reported in the literature; these results were obtained during a 6-year period when
staff were learning closed techniques.Technical failures of the closed technique can be avoided by paying attention
to well-established operative details. A system for grading outcomes was developed tocompare objectively the
results of treatment of fracture patients. The literature and the authors' experience support the adoption of closed
techniques forintramedullary rod insertion in femoral shaft fractures.

Bain, GI,. Zacest, AC., Paterson, DC., Middleton, J. & Pohl, AP.:
Abduction strength following intramedullary nailing of the femur.
J Orthop Trauma 1997, 11:293-7.
Abstracts: OBJECTIVES: To assess hip abductor function, strength and complaints following insertion of a
femoral intramedullary nail. DESIGN: Retrospective clinical review. SETTING: Department of Orthopaedics,
Adelaide Women's and Children's Hospital, Adelaide. Department of Orthopaedic Surgery and Trauma, Royal
Adelaide Hospital, Adelaide, South Australia, Australia. PATIENTS: 1. 32 of 37 patients who had an intramedullary
nail inserted for an isolated femoral shaft fracture at the Royal Adelaide Hospital between 1987 and 1990. 2. 14 of
18 patients who had closed femoral shortening for leg length discrepancy, at the Adelaide Women's and Children's
Hospital between 1985 and 1987. Patients with pathology involving the abductor mechanism were excluded. 3. 40
asymptomatic controls. INTERVENTION: Intramedullary fixation for femoral shaft fractures or as part of closed
femoral shortening. All procedures were performed on a traction table via a gluteal splitting approach with reamed
nails. MAIN OUTCOME MEASUREMENTS: Complaints included, pain, stiffness, limp and diminished walking
distance. Examination of abductor function and measurement of abductor strength. Radiological assessment at
followup. RESULTS: Complaints included trochanteric pain (40%, 40%), thigh pain (10%, 8%) and limp (13%,
42%) in the femoral fracture and closed femoral shortening groups respectively. There was significant difference in
the abduction strength (p < 0.01) and abduction ratio (p < 0.01) between the control and each treatment group.
Abductor weakness correlated (r = 0.30) with the incidence of complaints. CONCLUSION: Pain, limp and
weakness are common following insertion of a femoral intramedullary nail. Agluteal retracting approach may
minimize abductor weakness.

Bar-On, E., Sagiv, S. & Porat, S.:
External fixation or flexible intramedullary nailing for femoral shaft fractures in children.
A prospective, randomised study [see comments]
J Bone Joint Surg Br, 79(6):975-8 1997 Nov.
Abstracts: We report the outcome of 19 children aged 5.2 to 13.2 years with 20 fractures of the femoral shaft
requiring surgery, who were randomly assigned to have external fixation (EF) or flexible intramedullary nailing
(FIN) (10 fractures each). The duration of the operation averaged 56 minutes for the EF group with 1.4 minutes of
fluoroscopy, compared with 74 minutes and 2.6 minutes, respectively, for the FIN group. The early postoperative
course was similar, but the EF group showed much more callus formation. The time to full weight-bearing, full
range of movement and return to school were all shorter in the FIN group. The FIN complications included one
transitory foot drop and two cases of bursitis at an insertion site. In the EF group there was one refracture, one
rotatory malunion requiring remanipulation and two pin-track infections. At an average follow-up of 14 months two
patients in the EF group had mild pain, four had quadriceps wasting, one had leg-length discrepancy of over 1 cm,
four had malalignment of over 5 degrees, and one had limited hip rotation. In the FIN group, one patient had mild
pain and one had quadriceps wasting; there were no length discrepancies, malalignment or limitation of movement.
Parents of the FIN group were more satisfied. We recommend the use of flexible intramedullary nailing for fractures
of the femoral shaft which require surgery, and reserve external fixation for open or severely comminuted fractures.

Deshmukh, RG., Lou, KK., Neo, CB., Yew, KS., Rozman, I. & George, J. :
A technique to obtain correct rotational alignment during closed locked intramedullary nailing of the femur.
Injury 1998, 29, 3:207-10.
Abstracts: Closed intramedullary nailing is a successful method of treating adult femoral shaft fractures. In
comminuted or segmental fractures, this operation is associated with an incidence of rotational malalignment and
malunion. After locked nailing, this can only be corrected by further operation. A simple method of judging and
obtaining rotational alignment in such cases intra-operatively is described. A comparison of two groups of patients
with such fractures, one using this technique and the other using conventional methods of judging alignment,
revealed statistically significant improvement in rotational alignment (p = 0.016).

Reynders, P. & Broos, PL.:
Unreamed intramedullary nailing of femoral shaft fractures using a traction
device.
Injury 1998, 29, 1:81-4.
Abstracts: The authors present a simple distraction apparatus that is used in the sterile field and makes it possible to perform unreamed intramedullary nailing of the femur on a normal operation table. Intramedullary (IM) nails were
placed, without reaming, in 24 femoral shaft fractures with the use of this device. Although it appears as though the
use of the distractor did not lengthen the operative procedure, the set-up time was 60 per cent less compared with a
stratified group of 28 femoral nailing using the fracture table. We feel that this device provides a safe and effective
means for achieving fracture reduction without the need for a fracture table. It is especially useful in the multiply
injured patient where the additional lesions can be treated without the need for patient transfer to the fracture table.
 

[Rodilla]

Callahan, CM., Drake, BG., Heck, DA. & Dittus, R.:
Patient outcomes following tricompartmental total knee
replacement: a meta-analysis.
JAMA 1994, 271:1349-57.
Abstracts: The purpose of this study was to summarize the literature describing patient outcomes following
unicompartmental and bicompartmental knee arthroplasty. Original studies were included in this meta-analysis if
they enrolled 10 or more patients at the time of an initial knee arthroplasty and measured patient outcomes using a
global knee rating scale. Forty-six studies on unicompartmental prostheses and 18 studies on bicompartmental
prostheses met these criteria. For unicompartmental studies, the total number of enrolled patients was 2,391, with a
mean enrollment of 47 patients and a mean follow-up period of 4.6 years. The mean patient age was 66 years; 67%
were women, 75% had osteoarthritis, and 16% underwent bilateral knee arthroplasty. The mean postoperative global
rating scale score was 80.9. The overall complication rate was 18.5% and the revision rate was 9.2%. Studies
published after 1987 reported better outcomes, but also tended to enroll older patients and patients with osteoarthritis
and higher preoperative knee rating scores. For bicompartmental studies, the total number of enrolled patients was 884,
with a mean enrollment of 44 patients and
a mean follow-up period of 3.6 years. The mean patient age was 61 years; 79% were women, 31% had osteoarthritis,
and 29% underwent a bilateral arthroplasty. The mean postoperative global rating scale score was 78.3. The overall
complication rate was 30% and the revision rate was 7.2%. Although bicompartmental studies reported lower mean
postoperative global rating scale scores, these studies
tended to enroll patients with worse preoperative knee rating scores. Recent improvements in patient outcomes
following unicompartmental knee arthroplasty appear to be due, at least partially, to changes in patient selection
criteria. Patient outcomes appear to be worse for bicompartmental arthroplasties than for other prosthetic designs;
however, patients enrolled in these studies had more poorly functioning knees before surgery and actually had
greater absolute improvements in global knee rating scores.

Damron, TA. & McBeath, AA.:
Arthrodesis following failed total knee arthroplasty: comprehensive review
and meta-analysis of recent literature.
Orthopedics. 1995 Apr; 18, 4: 361-8.
Abstracts: With the increasing duration of follow up on total knee arthroplasties, more revision arthroplasties are
being performed. When revision is not advisable, a salvage procedure such as arthrodesis or resection arthroplasty is
indicated. This article provides a comprehensive review of the literature regarding arthrodesis following failed total
knee arthroplasty. In addition, a statistical meta-analysis of five studies using modern arthrodesis techniques is
presented. A statistically significant greater fusion rate with intramedullary nail arthrodesis compared to external
fixation is documented. Gram negative and mixed infections are found to be significant risk factors for failure of
arthrodesis.

Westrich, GH.:
The role of mechanical and other adjuncts.
Am J Knee Surg. 1999 Winter; 12, 1: 64-71.

Abstracts:
Abdel-Salam, A.& Eyres, KS.:
Effects of tourniquet during total knee arthroplasty. A prospective randomised study.
J Bone Joint Surg Br, 77, 2:250-3 1995 Mar.
Abstracts: The effects of using a tourniquet during total knee arthroplasty were studied in 80 patients randomly
allocated to two groups, either with or without a tourniquet. The groups were similar in mean age, gender,
preoperative knee score and radiographic grading and the patients were all operated on by the same surgeon using
one type of prosthesis. There was no significant difference between the two groups in operating time or total blood
loss but postoperative pain was less in the patients in whom a tourniquet had not been used. They achieved straight
leg raising and knee flexion earlier and had fewer superficial wound infections and deep-vein thromboses. Total
knee arthroplasty can be safely performed without the use of the tourniquet with the benefit that several adverse
effects associated with its use can be avoided.

Barwell, J., Anderson, G., Hassan, A., Rawlings, I. & Barwell, NJ. [corrected to Barwell J]:
The effects of early tourniquet release during total knee arthroplasty:
a prospective randomized double-blind study
[published erratum appears in J Bone Joint Surg Br 1997 Jul;79, 4:693]
J Bone Joint Surg Br, 79, 2:265-8 1997 Mar.
Abstracts: We studied the effects of the timing of tourniquet release in 88 patients randomly allocated for release
after wound closure and bandaging (group A), or before the quadriceps layer had been closed allowing control of
bleeding before suture (group B). The groups were similar in mean age, weight, gender, preoperative knee score,
radiographic grading, and prosthesis implanted. Patients in group B had less postoperative pain, achieved earlier
straight-leg raising, and had fewer wound complications. Five patients in group A had to return to theatre, three for
manipulation under anaesthesia, one for secondary closure of wound dehiscence, and one for drainage of a
haematoma. The last patient later developed a deep infection, which was treated by a two-stage revision. There were
no significant differences between the two groups in operating time, or the decrease in haemoglobin concentration at
48 hours postoperatively. Some of the adverse effects of the use of a tourniquet for knee surgery can be significantly
reduced by early tourniquet release, with haemostasis before the quadriceps mechanism and the wound are closed.

Benoni, G. & Fredin, H.:
Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood
transfusion after knee arthroplasty:
a prospective, randomised, double-blind study of 86 patients.
J Bone Joint Surg Br, 78(3):434-40 1996 May.
Abstracts: We investigated the effect of a fibrinolytic inhibitor, tranexamic acid, on blood loss and blood
transfusion in knee arthroplasty by a randomised, double-blind study of 86 patients. A dose of 10 mg/kg bodyweight
of either tranexamic acid or placebo was given intravenously shortly before the release of the tourniquet, and
repeated three hours later. The mean total blood loss was 730 +/- 280 ml in the tranexamic acid group as against
1410 +/- 480 ml in the placebo group (p < 0.001). Both the number of patients receiving blood transfusion and the
number of blood units transfused were reduced to one-third in the treated group, and mean postoperative Hb
concentrations were significantly higher after prophylaxis. The number of thromboembolic complications was the
same in both groups. Tranexamic acid should be given prophylactically in order to be effective.

Gunal, I., Taymaz, A., Kose, N., Gokturk, E. & Seber, S.:
Patellectomy with vastus medialis obliquus advancement for comminuted patellar fractures:
a prospective randomised trial.
J Bone Joint Surg Br, 79(1):13-6 1997 Jan.
Abstracts: We have compared the results of simple patellectomy (group A, n = 16) and patellectomy with
advancement of the vastus medialis obliquus (group B, n = 12) in a prospective, randomised trial, with a minimum
follow-up of three years. The results in group B were significantly better (p < 0.001) than those in group A.
Although the patella should be preserved if possible, we advocate advancement of the vastus medialis obliquus
when patellectomy is necessary.

Hede, A., Larsen, E. & Sandberg, H.:
Partial versus total meniscectomy. A prospective, randomized study
[Partiel versus total meniskektomi. Et prospektivt, randomiseret studie].
Ugeskr-Laeger 1994, 156, 1:48-52.
Abstracts: Two hundred patients with a meniscal lesion were peroperatively allocated to partial or total
meniscectomy in a random manner. The results were compared at one year and at 6.3 to 9.8 years (median 7.8).
After one year more patients with partial meniscectomy (90%) than with total meniscectomy (80%) had no
complaints. At the later review these figures were 62% and 52%, respectively (p = 0.18). However, patients with
partial meniscectomy had higher functional scores. The deterioration in function between the first review and the
second showed no significant difference in the two treatment groups. The incidence of mediolateral instability rose
from 8% to 47% and was more frequent after total than after partial meniscectomy. Between the two reviews the
radiological signs of knee degeneration increased with no difference between the two treatment groups.

Holt, BT., Parks, NL., Engh, GA. & Lawrence, JM.:
Comparison of closed-suction drainage and no drainage after primary total knee arthroplasty.
Orthopedics, 20(12):1121-4; discussion 1124-5 1997 Dec.
Abstracts: One hundred thirty-six primary total knee arthroplasty patients were randomized for the use of closed suction, nonreinfusable wound drains. Blood loss was identical in the drained and undrained groups. Forty percent
of undrained wounds compared with 0% of drained wounds required dressing reinforcement. Sixty-nine percent of
undrained wounds compared with 39% of drained wounds developed ecchymosis, measuring 92 cm2 in the
undrained group and 28 cm2 in the drained group. This study concludes that a simple wound drain effectively
minimizes the undesirable accumulation of blood in the surrounding soft tissues and the postoperative wound
dressing after total knee arthroplasty.

Lundin, O., Rydgren, B., Sward, L. & Karlsson, J.:
Analgesic effects of intra-articular morphine during and after knee arthroscopy:
a comparison of two methods.
Arthroscopy 1998, 14, 2:192-6.
Abstracts: The objective of this study was to compare the analgesic effects of intra-articularly administered
bupivacaine with bupivacaine/morphine during and after therapeutic knee arthroscopy. In a prospective, randomized
study, 50 patients with clinical signs of medial meniscal injury were allocated to two groups, A and B. The patients
in group A received 40 mL of 0.25% bupivacaine while the same dose of bupivacaine combined with 1 mg of
morphine sulphate was administered in group B. Pain was estimated using the visual analogue scale (VAS) during
surgery and at 2, 4, 6, and 24 hours after the operation was completed. Supplementary analgesic requirements were
also registered, as well as the patients' overall rating of the entire procedure. The pain scores were significantly
lower in Group B throughout the whole postoperative observation period. However, no significant differences were
found between the two groups in terms of intraoperative pain scores, supplementary analgesic requirements, or the
overall rating of the procedure. This study provides evidence that arthroscopic surgery can be performed in a safe
manner after intra-articularly administered bupivacaine with or without low-dose morphine. The combination of
low-dose morphine and bupivacaine did, however, produce a superior postoperative analgesic effect during the 24
hours following knee arthroscopy compared with bupivacaine alone.

O'Neill, DB.:
Open lateral retinacular lengthening compared with arthroscopic release.
A prospective, randomized outcome study.
J Bone Joint Surg Am, 79(12):1759-69 1997 Dec.
Abstracts: A prospective, randomized study was performed to compare the results of arthroscopic lateral retinacular
release (Group I) with those of open lateral retinacular lengthening (Group II). The study included eighty-six
patients (eighty-six knees) who had had pain in the anterior peripatellar aspect of the knee and lateral patellar tilting
(rotational malalignment), as seen on Merchant tangential patellofemoral radiographs, that had not improved after
participation in a structured rehabilitation program for the quadriceps and the hamstrings for a minimum of six
months. The mean duration of follow-up after the operative procedures was forty-six months (range, two to six
years). At the time of the latest follow-up evaluation, forty (93 per cent) of the forty-three patients in Group I and all
forty-three (100 per cent) of the patients in Group II had resumed the level of athletic activity that they had engaged
in before the onset of symptoms (p = 0.08, analysis of variance). With the numbers available for study, no
significant difference could be detected between the groups with regard to deficits in the range of motion, atrophy
(the circumference) of the thigh, operative or postoperative complications, or the need for subsequent operative
procedures. Additionally, no significantdifference could be detected between the groups with regard to the results of
open or closed-chain testing with an isokinetic dynamometer. According to the knee-rating system of Lysholm and
Gillquist as modified by Tegner and Lysholm, thirty-three knees (77 per cent) in Group I had a score of 80 points or
more compared with thirty-eight knees (88 per cent) in Group II. Six knees (14 per cent) in Group I had a score of
less than 70 points compared with no knees in Group II. The difference in the knee ratings between the two groups
was significant (p = 0.028, analysis of variance). Although there seemed to be a definite trend toward improved
function of the knee in association with a longer duration of follow-up, no significant association could be detected
between the duration of follow-up and improvement in the outcome measures in either group.

O'Neill, DB.:
Arthroscopically assisted reconstruction of the anterior cruciate ligament.
A prospective randomized analysis of three techniques.
J Bone Joint Surg Am, 78(6):803-13 1996 Jun.
Abstracts: One hundred and twenty-seven patients who had a rupture of the anterior cruciate ligament agreed to
participate in a prospective, randomized study of three arthroscopically assisted reconstruction techniques. One
hundred and twenty-five patients (125 reconstructions) were evaluated after a mean duration of follow-up of forty
two months (range, two to five years). Group I included forty patients who had a two-incision reconstruction with
use of an autogenous semitendinosus-gracilis graft, group II consisted of forty patients who had a two-incision
reconstruction with use of an autogenous patellar-ligament graft, and group III included forty-five patients who had
a single-incision reconstruction (endoscopic technique) with use of an autogenous patellar-ligament graft. The male
female ratio, age range, level of athletic activity, interval between the injury and the reconstruction, previous
operative procedures, and associated injuries were similar in all three groups. The same postoperative rehabilitation
protocol was followed for all patients. Testing with a KT-2000 arthrometer at maximum manual force was done at
the follow-up evaluation; the difference in laxity between the involved knee and the contralateral knee was three
millimeters or less in thirty-three patients (83 per cent) in group I, thirty-seven patients (93 per cent) in group II, and
thirty-nine patients (87 per cent) in group III. A difference of two millimeters or less was found in thirty patients (75
per cent) in group I, thirty-one patients (78 per cent) in group II, and thirty-five patients (78 per cent) in group III.
Thirty-five patients (88 per cent) in group I, thirty-eight patients (95 per cent) in group II, and forty patients (89 per
cent) in group III returned to at least the same level of athletic activity. Four grafts (two in group I and two in group
II) failed as a result of trauma. There was one additional failure in groups I and III, as evidenced by a difference of
nine and seven millimeters, respectively, on instrumented testing of laxity. The significant findings were that no
knee was rated D according to the system of the International Knee Documentation Committee (p < 0.002, 94 per
cent confidence level) and that fewer additional operative procedures were done on patients in group III (p < 0.08).
Also, it was found that the patients in group II returned to a greater level of athletic activity (p < 0.02) and that a
higher percentage of the patients in this group had a difference of three millimeters or less on testing with the KT-
2000 arthrometer than in the other two groups (p < 0.08). However, with the numbers available, there were no
significant differences in the over-all outcome among the three groups (p > 0.1). Importantly, the rate of failure was
not greater and the outcomes were not less satisfactory for the late reconstructions than they were for the acute
reconstructions (those performed less than three weeks after the injury), including those done with an autogenous
semitendinosus-gracilis graft in a chronically unstable knee.

Snyder-Mackler, L., Delitto, A., Bailey, SL. & Stralka, SW.:
Strength of the quadriceps femoris muscle and
functional recovery after reconstruction of the anterior cruciate ligament.
A prospective, randomized clinical trial of electrical stimulation.
J Bone Joint Surg Am, 77(8):1166-73 1995 Aug.
Abstracts: Immediately after reconstruction of the anterior cruciate ligament, 110 patients were randomly assigned
to treatment with high-intensity neuromuscular electrical stimulation (thirty-one patients), high-level volitional
exercise (thirty-four patients), low-intensity neuromuscular electrical stimulation (twenty-five patients), or combined
high and low-intensity neuromuscular electrical stimulation (twenty patients). All treatment was performed
isometrically with the knee in 65 degrees of flexion. All of the patients participated in an intensive program of
closed-kinetic-chain exercise. After four weeks of treatment, the strength of the quadriceps femoris muscle and the
kinematics of the knee during stance phase were measured. Quadriceps strength averaged 70 per cent or more of the
strength on the uninvolved side in the two groups that were treated with high-intensity electrical stimulation (either
alone or combined with low-intensity electrical stimulation), 57 per cent in the group that was treated with highlevel
volitional exercise, and 51 per cent in the group that was treated with low-intensity electrical stimulation. The
kinematics of the knee joint were directly and significantly (p < 0.05) correlated with the strength of the quadriceps.
There was a clinically and statistically significant (p < 0.05) difference in the recovery of the quadriceps and the gait
parameters according to the type of operation that had been performed: the patients who had had reconstruction of
the anterior cruciate ligament with use of an autologous patellar-ligament graft did poorly compared with the other
patients.

Wilson-MacDonald, J., Dodd, C. & Cockin, J.:
Arthroscopy in acute knee injuries: a prospective controlled trial.
Injury 1990, 21, 3:165-8.
Abstracts: Eighty-two patients took part in a prospective trial to assess the need and timing for arthroscopy in acute
knee injuries. Patients with a suspected ligament injury, a suspected meniscal tear, or a haemarthrosis in the absence
of fracture were included in the trial. Patients were entered randomly into two groups. In group I early arthroscopy
was performed (within 48 h), in group II arthroscopy was performed within 21 days, but only when it was felt to be
clinically indicated. Patients were assessed using the OAK knee score 1 year after the injury. There was no
difference in the final result between the two groups. Early arthroscopy (within 48 h) showed no beneficial effect
when compared with delayed arthroscopy (3 to 21 days after the injury). Indeed, an important diagnosis was missed
at early arthroscopy in three cases, which led to delay in subsequent diagnosis and treatment. Arthroscopy raised the
diagnostic accuracy from 61 per cent to 93 per cent. Considerable morbidity arises as a result of acute knee injuries.
Clinical judgment will correctly define the need for arthroscopy in most cases at the time of injury, and arthroscopy
is not necessary in all cases of acute haemarthrosis.

Zhang, Z. & Arnold, JA.:
Trephination and suturing of avascular meniscal tears:
a clinical study of the trephination procedure.
Arthroscopy 1996, 12, 6:726-31.
Abstracts: On the basis of animal studies, an arthroscopic surgical system and procedure of trephination plus
suturing were designed for clinical practice. The system consists of a trephine with a tooth-like tip, a guide, and an
ordinary arthroscopic power handle. The guide introduces the trephine to the tear without abrading articular cartilage
and controls the depth of the trephination. The power handle connected to a suction system provides an inside-out
cut core of meniscal tissue. Thirty-six patients with meniscal tears underwent arthroscopic trephination plus suturing
(group TS) and 28 patients had suturing alone (group S). The follow-up was 25 to 78 months. Two symptomatic
retears have occurred in group TS and 7 symptomatic retears in group S. The symptomatic retear rate of group TS
was significantly smaller than group S (P < .01). It is indicated that the patients treated with trephination have fewer
symptoms and lower clinical failure rate. Arthroscopic trephination is a safe and easy procedure.
 

[Pierna]
 
 

Dervin GF.:
Skeletal fixation of grade IIIB tibial fractures: the potential of metaanalysis.
Clin Orthop 1996, 332:10-15.
Abstracts: Contemporary management of Grade IIIB open tibial fractures has evolved to include intravenous
antibiotics, thorough interval surgical debridement, rigidskeletal fixation, early local or free tissue myoplasty, and
liberal use of autogenous bone graft beneath a clean, stable wound. External fixation has been the
skeletalstabilization of choice with the lowest reported deep sepsis rates. Pin tract infection, malunion, and nonunion
have complicated its use. Static unreamed locked nailingis an alternative treatment that has been successfully used in
lower grade open tibial fractures. A metaanalysis of the literature was undertaken to determine whetherthere was
evidence favoring 1 method of skeletal fixation. Inclusion criteria were restricted to studies that were randomized to
either external fixation or unreamedintramedullary nail methods and that used a strict definition of Grade IIIB to
include muscle transfer for soft tissue coverage. Two studies were identified andcombined to show no difference in
deep sepsis rate. Intramedullary nailing significantly shortened union time whereas external fixation showed a trend
toward a higherincidence of malunion and superficial sepsis. More well designed randomized studies would add to
this initial effort and yield more compelling evidence for either formof fixation.

Littenberg, B., Weinstein, LP., McCarren, M., Mead, T., Swiontkowski, MF., Rudicel, SA. & Heck, D.:
Closed fractures of the tibial shaft: a meta-analysis of three methods of treatment.
J Bone Joint Surg 1998, 80-A, 2:174-183.
Abstracts: We reviewed the literature to determine the clinical outcomes of the treatment of closed fractures of the
tibial shaft with immobilization in a cast, open reduction with internal fixation, or fixation with an intramedullary
rod. We reviewed 2372 reports of comparative trials and uncontrolled studies of series of patients published between
1966 and 1993. Nineteen reports, involving six controlled trials and twenty-seven groups of patients, met our
inclusion criteria. A structured questionnaire was used to assess the quality of the literature in terms of the
experimental design and the method of assessment of outcome. Outcomes from controlled trials were summarized
with odds ratios and risk differences, and outcomes from case series were summarized by the medians of the
reported results.

Antich-Adrover, P., Marti-Garin, D., Murias-Alvarez, J. & Puente-Alonso, C.:
External fixation and secondary intramedullary nailing of open tibial fractures.
A randomised, prospective trial.
J Bone Joint Surg 1997, 79-B:433-37.
Abstracts: We performed a prospective, randomised trial in 39 patients with open tibial fractures treated initially by
external fixation to compare cast immobilisation(group A) and intramedullary nailing (group B) as a sequential
protocol planned from the onset of treatment. The results showed that group B achieved faster union (p< 0.05) than
group A with less malunion or shortening and a greater range of movement. Patients treated by intramedullary
nailing required fewer radiographs andoutpatient visits (p = 0.0015) and had a more predictable and rapid return to
full function. We feel that these severe fractures are better treated by delayedintramedullary nailing and that this has
an acceptable rate of complications.

Blachut PA; O'Brien PJ; Meek RN; Broekhuyse HM.:
Interlocking intramedullary nailing with and without
reaming for the treatment of closed fractures of the tibial shaft.
A prospective, randomized study.
J Bone Joint Surg Am, 79(5):640-6 1997 May.
Abstracts: One hundred and fifty-two patients who had 154 closed fractures of the shaft of the tibia were
prospectively randomized to management with interlocking intramedullary nailing either with or without reaming.
Thirteen patients who had been randomized to treatment without reaming were switched to the group that had
reaming because of technical reasons; these patients were excluded from the analysis of the results. An additional
five patients were lost to follow-up. Thus, seventy-two patients (seventy-three fractures) who had been managed
with nailing with reaming and sixty-three patients (sixty-three fractures) who had been managed with nailing
without reaming were available for follow-up at an average of twelve months (range, three to thirty-three months)
postoperatively.The two groups were similar with regard to demographics and the configurations of the fractures.
The average total duration of the procedures performed without reaming was eleven minutes shorter than that of the
procedures done with reaming (p = 0.0013). The duration of fluoroscopy was not significantly different between the
two groups (p = 0.35, Mann-Whitney test). The average estimated blood loss was identical for the two
groups.Seventy fractures (96 per cent) that were treated with nailing with reaming and fifty-six (89 per cent) that
were treated with nailing without reaming united without the need for an additional operation (p = 0.19). Because of
the small sample size, the study has insufficient power (34.7 per cent) to detect this difference if it is real.There was
only one deep infection, which developed after nailing without reaming. The nail fractured after one procedure with
reaming. A screw fractured after two procedures with reaming and after ten with out reaming (p = 0.012); multiple
screws fractured after three procedures in the latter group.Malunion occurred after three nailing procedures with
reaming and after two without reaming. Four malunions were of very proximal fractures and one was of a very distal
fracture. Seventeen screws and twenty four nails were removed after nailing with reaming, and twenty screws and
nineteen nails were removed after nailing without reaming; neither of these prevalences was significantly different
between the two groups (p=0.27 and 0.89; chi-square test).We concluded that there are no major advantages to
nailing without reaming as compared with nailing with reaming for the treatment of closed fractures of the shaft of
the tibia. There was a higher prevalence of delayed union and breakage of screws after nailing without reaming.

Court-Brown CM; Will E; Christie J; McQueen MM.:
Reamed or unreamed nailing for closed tibial fractures.
A prospective study in Tscherne C1 fractures [see comments].
J Bone Joint Surg Br, 78(4):580-3  1996 Jul.
Abstracts: We performed a prospective, randomised study on 50 patients with Tscherne C1 tibial diaphyseal
fractures comparing treatment with reamed and unreamed intramedullary nails. Our results show that reamed nailing
is associated with a significantly lower time to union and a reduced requirement for a further operation. Unreamed
nailing should not be used in the treatment of the common Tscherne C1 tibial fracture.

McKee, MD., Schemitsch, EH., Waddell, JP. & Yoo, D.:
A randomized clinical trial comparing tibial nailing
using standard fracture table traction versus manual traction.
J Bone Joint Surg 1997, 79-B:81.
Abstracts: OBJECTIVE: We sought to determine the effectiveness of intramedullary tibial nailing using manual
traction with the leg draped free versus standard fracture table positioning and traction. STUDY DESIGN:
Prospective, randomized clinical trial. METHODS: Eighty-five tibial shaft fractures (in seventy-nine patients)
treated by intramedullary nailing were randomized either to manual traction with the leg draped free or to standard
fracture table traction applied through a boot attachment. RESULTS: We found that manual traction provided
results, in terms of intraoperative parameters and quality of fracture reduction, similar to those with standard fracture
table traction. Manual traction significantly reduced positioning time (twelve minutes versus twenty-five minutes,
p = 0.002) and also allowed for multiple simultaneous or sequential procedures in polytrauma patients without the
need for re-positioning or re-draping. This saved a further thirty-two minutes (mean) in 37 percent of cases treated
by manual traction.
CONCLUSION: Manual traction for intramedullary nailing of the tibia is an effective technique that can save a
significant amount of time without sacrificing the quality of reduction or fixation of tibial shaft fractures. It is especially
useful in polytrauma patients with multiple lower-extremity injuries.

Westrich, GH. & Sculco, TP.:
Prophylaxis against deep venous thrombosis after total knee arthroplasty.
Pneumatic plantar compression and aspirin compared with aspirin alone.
J Bone Joint Surg Am, 78(6):826- 34 1996 Jun.
Abstracts: A prospective, randomized study was conducted to assess the efficacy of pulsatile pneumatic plantar
compression for prophylaxis against deep venous thrombosis after total knee arthroplasty performed with use of
regional anesthesia. One hundred and twenty-two patients (164 knees) who were scheduled to have a unilateral or a
one-stage bilateral total knee arthroplasty were separately randomized to be managed with either aspirin alone or the
pulsatile pneumatic plantar-compression device and aspirin. The prevalence of deep venous thrombosis was 27 per
cent (twenty-two of eighty-one knees) in the group treated with pneumatic plantar compression compared with 59
per cent (forty-nine of eighty-three knees) in the patients managed with aspirin alone (the control group) (p < 0.001).
A significant difference was also noted in the group that had had a unilateral arthroplasty (a prevalence of 27 per
cent [eleven of forty-one knees] in the group treated with pneumatic plantar compression, compared with 67 per cent
[twenty-six of thirty-nine knees] in that treated with aspirin alone; p < 0.006) and in the group that had had a one stage
bilateral procedure (a prevalence of 28 per cent [eleven of forty knees] in the group treated with pneumatic
plantar compression, compared with 52 per cent [twenty-three of forty-four knees] in that treated with aspirin alone;
p < 0.03). No proximal thrombi were noted in any patient who used the pulsatile pneumatic plantar-compression
device, while the prevalence of proximal thrombosis in the popliteal or femoral veins was 14 per cent (twelve of
eighty-three knees) in the group treated with aspirin alone (p < 0.0003). In the group treated with a unilateral
procedure and aspirin alone the prevalence of proximal thrombosis was 13 per cent (five of thirty-nine knees; p <
0.02), while in the group treated with a bilateral procedure and aspirin alone it was 16 per cent (seven of forty-four
knees; p < 0.01). Only in the patients who had had a unilateral procedure was use of the compression device
associated with significantly less edema postoperatively than was use of aspirin alone. The change between the
preoperative and postoperative circumferences of the thigh and leg was significantly less (9 +/- 4.1 millimeters
[mean and standard deviation] less for the thigh [p < 0.01] and 6 +/- 3.9 millimeters less for the leg [p < 0.049])
with the compression device than with aspirin alone. In addition, there was significantly less mean drainage (98 +/-
61.1 milliliters) in the group treated with a unilateral procedure and pneumatic compression, compared with that
treated with a unilateral procedure and aspirin alone (p < 0.041). An internal timer of the compression device was
used to assess the compliance of the patient with use of the device, and a relationship between deep venous thrombosis
and the total duration of treatment with the device was found. The patients in whom deep venous thrombosis did not
develop used the device for a mean of 96 +/- 23.4 hours (range, sixty to 164 hours) postoperatively, or 19.2 +/- 5.1
hours a day, while those in whom thrombosis developed used it for a mean of 67 +/- 21.1 hours (range, twenty-six to
101 hours), or 13.4 +/- 4.3 hours a day (p < 0.001). No untoward effects were noted in any patient who used the device.
This study confirms the safety and efficacy of pulsatile pneumatic plantar compression and aspirin compared with aspirin
alone and supports the use of mechanical compression for prophylaxis against deep venous thrombosis and for reduction
of edema in patients who have had a total knee arthroplasty. In addition, we found a direct relationship between
compliance with the use of this device and its efficacy in reducing deep venous thrombosis.

Court-Brown, CM. & McBirnie, J.:
The epidemiology of tibial fractures.
J.Bone and Joint Surg May 1995, 77-B, 3:417-21.
Abstracts: We performed an epidemiological analysis of 523 fractures treated in the Edinburgh Orthopaedic
Trauma Unit over a three-year period using moderndescriptive criteria. The fractures were defined in terms of their
AO morphology and their degree of comminution, location and cause. Closed fractures wereclassified using the
Tscherne grading system and open fractures according to the Gustilo classification. Further analysis of fractures
caused by road-traffic accidentsand football was carried out. The use of the AO classification allowed the common
fracture patterns to be defined. Correlation of the classification systems showed an association between theAO
morphological system and the Tscherne and Gustilo classifications. The relative rarity of severe tibial fractures is
indicated and it is suggested that in smallerorthopaedic units the infrequency of these fractures has implications for
training and the development of treatment protocols.
 

[Tobillo y pie]
 
 

Springer, MA. Van Binsbergen, EA., Patka, P. Bakker, FC. & Haarman, HJ.:
Resorbable rods and screws for fixation of ankle fractures.
A randomized clinical prospective study [Resorbierbare Stabe und Schrauben
zur Fixierung von Knochelfrakturen. Eine randomisierte klinische Prospektivstudie].
Unfallchirurg 1998, 101:5377-81.
Abstracts: A prospective randomized clinical trial was performed to evaluate the use of self-reinforced absorbable
composites (Biofix) in the fixation of ankle fractures. The aim of this study was to demonstrate that fixation with
Biofix rods and screws is as good as the standard A.O. fixation. The benefits of Biofix rods and screws are: a
reduction in costs since no secondary operation is needed, prevention of stress-shielding and thereby diminishing the
risk of bone porosity. Patients aged between 16 and 75 years old with closed, non-comminuted fractures of the
lateral and/or medial malleolus and dislocation of the fracture fragments greater than 2 mm were included in the
study. 22 patients were treated with Biofix rods and screws and the control group of 19 patients with a standard
technique. After 3, 6 and 12 months, rontgenograms were taken. At the same time functional results were evaluated
following the criteria of Olerud and Molander. Two patients were withdrawn from the trial for non-medical reasons.
22 patients (12 from the Biofix group, 10 from the AO group) operated two or more years ago were contacted to see
if any complications had occurred since they were last seen. In 4 cases a Biofix screw broke down just beneath the
head during insertion. This did not result in an insufficient fixation of the fracture. There were no early postoperative
complications. The functional and rontgenological results in both groups were equal. In three cases a
sterile sinus developed at the site of screw insertion. Biofix rods and screws, made of polylactic acid, are a good
alternative for the fixation of fractures of the ankle. The use of resorbable fracture fixation material has the
advantage that a second operation to remove osteosynthesis material is not necessary. The long term results are
good. There is, however, a possibility of development of tissue reaction to the resorbable material.
Erdmann MWH, Richardson J, Templeton J. Os calcis fractures: a randomized trial comparing conservative treatment
with impulse compression of the foot. Injury 1992, 23, 5:305-07.
Abstracts: Published data suggest that soft tissue involvement plays a role in the aetiology of residual symptoms
following fractures of the os calcis. This randomized study involved 23 patients with 24 intra-articular fractures of
the calcaneum. It was designed to evaluate the efficacy of a pneumatic plantar impulse device in reducing pain,
associated morbidity and convalescent time. The results show a significant improvement in subtalar range of
movement in the pumped group at 3 months, with pain significantly reduced at 6 months and at I year. There was no
difference in weight bearing or walking distance between the pumped and control groups. The time from date of
injury to return to work was significantly reduced in the pumped group by an average of 3 months.

Finsen V; Kasseth AM.:
Tourniquets in forefoot surgery: less pain when placed at the ankle.
J Bone Joint Surg Br, 79(1):99-101 1997 Jan.
Abstracts: We studied perioperative pain and postoperative neurological changes after surgery for hallux valgus in
50 patients operated on under local ankle block. Patients were randomised to have the pneumatic tourniquet either at
calf level or just above the ankle. The cuffs were inflated to 100 mmHg above systolic blood pressure. One patient
was withdrawn from the study after randomisation. Areas of pain, paraesthesia and numbness were marked by
patients on a diagram of the foot before operation and at six and ten weeks after operation. Both positions of the
tourniquet gave an excellent bloodless field. The proximal tourniquet gave significantly greater discomfort (p <
0.01) during the operation, after 10, 20 and 30 minutes. Application of the cuff at the ankle gave no relative increase
in areas of numbness and paraesthesia at six and ten weeks. An ankle tourniquet gives less discomfort with no
increase in the incidence of nerve injury.

O´Farrell, DA., O´Byrne, JM., McCabe, JP. & Stephens, MM.:
Fractures of the os calcis: improved results with internal fixation.
Injury 1993, 24, 4:263-65.
Abstracts: A prospective study of 24 patients with displaced intra-articular fractures of the os calcis was performed
to compare operative with non-operative treatment. Twelve patients were treated by internal fixation followed by
early mobilization, and 12 were managed non-operatively. The patients were assessed 15 months later using eight
parameter Of the 12 patients who were treated by internal fixation, eight had returned to work. Walking distance
was significantly longer (4 km) in this group and only one patient needed a change in shoe size. Of the 12 patients
who were managed non -operatively, only three had returned to work and eight had a change in shoe size, while the
average walking distance without pain was only I km. The mean range of subtalar movement was 24' in the operated
group but only 12' in the other group (P< 0. 05). Radiological follow-up demonstrated partial or full restoration of
Böhler´s angle in the patients who underwent internal fixation. We recommend plating of displaced intraarticular os
calcis fractures through a lateral approach in patients under 40 years of age.

O´Farrell, DA., McCabe, JP., O´Byrne, JM. & Stephens, MM.:
Operative treatment of fracture of the os calcis.
Br J Surg 1993, 80:S102.

Abstracts:
Lowrie, IG., Triffitt, PD. & Gregg, PJ.:
A controlled, prospective, randomised trial of operative versus
conservative treatment of displaced intra-articular fractures of the os calcis:
a preliminary report.
J Bone Joint Surg 1990, 72-B:948.
Abstracts: Compared open reduction with closed treatment (bed rest for a week, physioterapy and non-weight bearing for eight to nine weeks) for the management of displaced intra-articular fractures of the calcaneum. Open
reduction was performed in the first week, plaster fixation continued for six week with non-weight-bearing for eight
to nine weeks. Kirschner wire used for fixation were removed. CT scan were used to assess the fracture geometry. In
all, 37 feet were review, 17 managed by open operation and 20 by closed methods. The average age was similar in
both groups, but there was a slight preponderance of men in the operative group and the inverted-Y type of fracture
in the closed group. No case treated conservatively had any improvement in the position of the fragments. Of many
posoperative assessment made, it was pain which most influence patient satisfaction; this was significantly less
frequent (p<0,002) in operated cases, the ratio being 0,39 between operative and closed treatement groups. Most
results favoured the operative group, except that they took longer to recover than those treated conservatively, but
differences were not statistically significant.

Parmar, HV., Triffitt, PD., Lowrie, IG. & Gregg, PJ.:
A prospective randomized trial of operative and
conservative treatment of displaced intra-articular fractures of the os calcis.
J Bone Joint Surg 1992, 74-B, Suppl 3:269.
Abstracts: Los autores presentan un estudio de 163 pacientes con presunción de fractura intraarticular de calcaneo
que fueron admitidos en un estudio prospectivo aleatorio. A todos se les realizó un TAC al ingresar, para establecer
tanto si la fractura era intraarticular, y evaluar el desplazamiento. El tratamiento quirúrgico comprendía reducción de
los fragmentos articulares por abordaje lateral y fijación con agujas de Kirschner, seguido de 6 semanas con vendaje
de yeso. El tratamiento conservador comprendía elevación y movilización precoz del tobillo y de la subastragalina.
En ambos grupos, no se permtió soporte de carga en 6 semanas. En la revisión se le preguntó a los pacientes sobre el
nivel de dolor (usando una escala analógica visual, utilización de analgésicos, habilidad para caminar en diferentes
superficies, vuelta al trabajo y a actividades recreativas. Tambien fueron examinados la deformidad del talón, el
nivel de movilidad del tobillo y la subastragalina, y la habilidad para saltar y mantenerse erguido de puntillas.
Cincuenta y cinco pacientes con fractura intraarticular fueron revisados como mínimo al año, incluyendo 38
estudiados al menos dos años. Cuarenta y cinco fracturas desplazadas han sido aleatorizadas en los grupos,
quirúrgico (22) y conservador (23). Los autores no pudieron encontrar diferencias estadisticamente significativas
entre los grupos pero el grupo quirúrgico demostró una mayor tendencia a la mejoría en la medición de resultados,
particularmente en los hombres en edad de trabajar. Entre los tratados conservadoramente, habia 23 fracturas
desplazadas o no. Este grupo tenía una mayor incidencia de dolor evidente y un bajo nivel global de satisfacción.

Parmar, HV., Triffitt, PD. & Gregg, PJ.:
Intra-articular fractures of the calcaneum treated operatively or
conservatively. A prospective study.
J Bone Joint Surg 1993, 75-B:932-37.
Abstracts: We report a prospective trial of 66 patients with intra-articular fractures of the calcaneum. All fractures
were assessed by CT. Patients with displaced fractures were randomised to receive either conservative (n = 31) or
operative treatment (n = 25). Undisplaced fractures (n = 10) were treated conservatively. Operation involved open
reduction of the posterior subtalar joint, and fixation with Kirschner wires. All 66 patients were reviewed at a
minimum of one year (mean 23 months). After conservative treatment the undisplaced fractures had slightly better
results than the displaced fractures. There was no significant difference in outcome between the operatively and the
conservatively treated displaced fractures. We have also documented prospectively the natural history of the injury,
which is of use in assessing prognosis for both clinical and medicolegal purposes.

Povacz P; Unger SF; Miller WK; Tockner R; Resch H.:
A randomized, prospective study of operative and
non-operative treatment of injuries of the fibular collateral ligaments of the ankle.
J Bone Joint Surg Am, 80(3):345-51 1998 Mar.
Abstracts: One hundred and forty-six adults who had an isolated injury of the fibular collateral ligaments of the
ankle were randomized to be managed operatively or non-operatively. Disruption of the ligaments was diagnosed by
means of a physical examination and on the basis of stress radiographs of the ankle made with use of a specially
designed device to hold the leg. Operative treatment, performed in seventy-three patients, consisted of suture repair
of the disrupted ligaments within seventy-two hours after the injury, followed by immobilization of the ankle in a
below-the-knee plaster cast for six weeks. Non-operative treatment, used for seventy-three patients, consisted of the
use of an ankle orthosis for six weeks. After a minimum of two years of follow-up, we could detect no significant
differences, with the numbers available, between the two groups with regard to the functional result or the degree of
joint laxity that was evident on stress radiographs. The non-operative group lost a mean of 1.6 weeks from work,
and the operative group lost a mean of 7.0 weeks. We concluded that non-operative treatment of an injury of the
fibular collateral ligaments of the ankle yields results that are comparable with those of operative repair and is
associated with a shorter period of recovery.

Thordarson, DB. & Krieger, LE.:
Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus:
a prospective randomized trial.
Foot Ankle Int 1996, 17, 1:2-9.
Abstracts: Thirty patients with displaced, intra-articular calcaneus fractures were randomized to operative or
nonoperative treatment. All patients had two or three major articular fragments of the posterior facet (Sanders type II
or III). Nonoperative treatment included early mobilization and delayed weightbearing. Operative treatment
involved open reduction and rigid internal fixation with a plate and screws through an extensile, L-shaped lateral
approach followed by early mobilization and delayed weightbearing. Fifteen operative patients were evaluated at an
average of 17 months follow-up and 11 nonoperative patients were seen at 14 months average follow-up. In the
operative group, there were 7 excellent results, 5 good results, 2 fair results, and 1 poor result, and in the
nonoperative group there was 1 excellent result, 3 good results, 1 fair result, and 6 poor results (difference
significant at P < 0.01). A functional scoring system of 0–100 points was developed based upon the responses to an
outcome assessment questionnaire. The average functional score for the operative group was far superior at 86.7,
compared with 55.0 for the nonoperative group (P < 0.0001). Subtalar range of motion averaged 20° for the
operative group and 17° for the nonoperative group with pain on extremes of motion of 25% of the operative
patients compared with 100% of the nonoperative patients. This study is the first prospective, randomized trial to
demonstrate the superior results of current operative treatment with early mobilization compared with nonoperative
treatment.