SummaryObjective. To compare efficacy, safety, and feasibility of adjusted- dose oral anticoagulants (OAC) versus fixed-dose subcutaneous low molecular weight heparin (LMWH) for the prevention of deep venous thrombosis (DVT) in patients who have undergone elective hip or knee replacement.Design. Multicentre, single blind randomised trial. OAC (acenocoumarol, target International Normalised Ratio, 2.0-3.0) and LMWH (nadroparine, 60 aXa IU/kg once daily) were started preoperatively and continued for 10 days. All outcome measures were adjudicated by an independent committee unaware of treatment allocation.Subjects. 672 consecutive patients scheduled for elective hip or knee replacement surgery. All patients wore bilateral graduated compression stockings.Main outcome measures. The endpoint for the assessment of efficacy was venography confirmed DVT or confirmed symptomatic pulmonary embolism. The endpoint for the assesment of safety was clinically important bleeding during study treatment or within 48 h of the end of treatment.Results. Among the 517 patients with interpretable venograms, 391 had a hip replacement and 126 had a knee implant. DVT was demonstrated in 50 (20%) of 257 patients allocated to OAC and 43 (17%) of 260 patients allocated to nadroparine (p = 0.45), for an absolute difference in DVT incidence of 2.9% in favour of nadroparine (95% Cl, -3.7-9.5). Clinically important bleeding occurred in eight (2.3%) of the 342 oral anticoagulant treated patients and in five (1.5%) of the 330 nadroparine treated patients (p = 0.62), for an absolute difference in favour of nadroparine of 0.8% (95% Cl, -1.3-2.9).Conclusion. Patients who undergo major orthopaedic operations have a high risk of venous thromboembolism. Once daily fixed-dose subcutaneous nadroparine is at least as efficacious and safe as daily adjusted OAC for prophylaxis against DVT after hip or knee implantation but is more simple to administer.

Brace application has been reported to be effective in treating idiopathic adolescent scoliosis. The exact working mechanism of a thoracolumbo spinal orthosis is a result of different mechanisms and is not completely understood. One of the supposed working mechanisms is a direct compressive force working through the brace upon the body and thereby correcting the scoliotic deformity, achieving optimal fit of the individual orthosis. In this study we measured these direct forces exerted by the pads in a Boston brace in 16 patients with idiopathic adolescent scoliosis, using the electronic PEDAR measuring device (Novel, Munich, Germany). This is designed as an in-shoe measuring system consisting of two shoe insoles (size 8 1/2), wired to a computer, recording static and dynamic pressure distribution under the plantar surface of the foot. After positioning the inserts between the lumbar and thoracic pads and the body, we measured the forces acting upon the body in eight different postures. In all positions the mean corrective force through the lumbar brace pad was larger than the mean corrective force over the thoracic brace pad. Some changes in body posture resulted in statistically significant alterations in the exerted forces. There was no significant correlation between the magnitude of the compressive force over the lumbar and thoracic brace-pad and the degree of correction of the major curve. Comparing the corrective forces in a relatively new (<6 months) and old (>6 months) brace, there was no statistically relevant difference, although the corrective force was slightly larger in the new braces. We think that the use of this pressure measurement device is practicable and of value for studies of the working mechanism of brace treatment, and in the future it might be of help in achieving optimal fit of the individual orthosis.

We report two cases of dystrophic scoliosis in neurofibromatosis, each of particular interest. In the first, kyphosis was present with vertebral rotatory subluxation but no neurologic impairment, while the second patient showed manifest paraplegia due to rapidly progressive kyphoscoliosis. The importance of early surgical stabilisation, both front and back if possible, is stressed. Very sharp curves with progressive myelopathy should not be treated with halofemoral traction because of the potential danger of evoking permanent paraplegia.

No abstract