Incidence and predictive factors of problems after fixation of trochanteric hip fractures with sliding hip screw or intramedullary devices.

INTRODUCTION: Hip fractures are common and disabling injuries, usually managed surgically. The most common type outside the joint capsule are trochanteric fractures, usually fixed with either sliding hip screw or intramedullary nail. Data are available in the National Hip Fracture Database (NHFD) on early failure and other major complications, but late or subtler complications may escape recording. This study sought to quantify such problems after fixation performed at 3different sites and identify their predictors. METHODS: Patients with a trochanteric fracture treated at 1 of 3 sites were identified from the NHFD over a 3-year period. Any with further, related episodes of care were identified, and reasons recorded, then age- and sex-matched with those with no such episodes. Data was collected on Arbeitsgemeinschaft für Osteosynthesefragen classification, tip-apex distance, American Society of Anesthesiologists (ASA) grade, Abbreviated Mental Test Score and pre-injury mobility. The cohorts were compared, and a binomial logistic regression model used to identify predictors of problems. RESULTS: A total of 4010 patients were entered in the NHFD across 3 sites between January 2013 and December 2015. Of these, 1260 sustained trochanteric fractures and 57 (4.5%) subsequently experienced problems leading to re-presentation. The most common was failure of fixation, occurring in 22 patients (1.7%). The binomial logistic regression model explained 47.6% of the variance in incidence of postoperative problems with ASA grade and tip-apex distance being predictive. DISCUSSION: The incidence of re-presentation with problems was around of 5%. A failure rate of less than 2% was seen, in keeping with existing data. This study has quantified the incidence of subtler postoperative problems and identified their predictors. The type of implant used was not amongst them and patients with both implants experienced problems. Fixation continues to yield imperfect results, but patient health and robust surgical technique remain important factors in a good outcome.

The first Pleistocene fossil records of Urtica kioviensis Rogow. (Urticaceae) and Potamogeton sukaczevii Wieliczk. (Potamogetonaceae) in the British Isles.

Seeds of the extant Urtica kioviensis Rogow. (Urticaceae) and endocarps of the extinct Potamogeton sukaczevii Wieliczk. (Potamogetonaceae) were recorded in diverse plant macrofossil assemblages recovered from organic sediments exposed during excavations at Saham Toney, Norfolk, UK. Aminostratigraphical data show the sediments were deposited during the Ipswichian (Last Interglacial) Stage. Palynological data indicates deposition during the Carpinus pollen zone of the Ipswichian Stage-the latter part of pollen zone Ip IIb and Ip III. The records are noteworthy not only because they are the first in the British Pleistocene but also because of the geographical occurrences of these two species. Urtica kioviensis is absent from the British flora today and has a modern range in central and eastern Europe (only extending as far west as north-east Germany and Denmark), while the extinct Potamogeton sukaczevii has only been recovered from Late Pleistocene sediments in Belarus, Lithuania, Poland and western Russia. The presence of U. kioviensis along with other exotic species to the British Isles (e.g. Najas minor L. and Salvinia natans L., which today have central and southern ranges in Europe and in the case of S. natans occurs on other continents) may point to more continental conditions or warmer summer conditions during the second half of the Ipswichian Stage in southern Britain. No modern analogues occur in Britain for the assemblages recovered from Saham Toney. Evidence of colder winters or at least warmer summers at the time of deposition does not support the view that sea-level peaked in the Carpinus zone of the Eemian Stage (correlated with the Ipswichian Stage) associated with increased oceanicity. Southern Britain would have been under the influence of the Atlantic Ocean and a degree of oceanicity is supported by the presence of two thermophilous taxa, Hedera and Ilex, in the pollen spectra from Saham Toney. Alternative explanations for the presence of these exotic species are that they were tolerating mild winters and cooler summers at the time of deposition or exploiting suitable micro-environments. The distribution of P. sukaczevii is probably an artefact of the distribution of expertise in the identification of Potamogeton fossil endocarps rather than having any palaeogeographic or palaeoclimatic significance. It is an extinct ancestor of the extant P. maackianus A. Benn, an eastern Asian pondweed. Its discovery in Britain encourages a reassessment of plant macrofossil assemblages from western Europe, which may lead to a consideration of the relationship between the Late Pleistocene vegetation of Europe and eastern Asia.

Abnormally Methylated FMR1 in Absence of a Detectable Full Mutation in a U.S.A Patient Cohort Referred for Fragile X Testing.

In 2016, Methylation-Specific Quantitative Melt Analysis (MS-QMA) on 3,340 male probands increased diagnostic yield from 1.60% to 1.84% for fragile X syndrome (FXS) using a pooling approach. In this study probands from Lineagen (UT, U.S.A.) of both sexes were screened using MS-QMA without sample pooling. The cohorts included: (i) 279 probands with no FXS full mutation (FM: CGG > 200) detected by AmplideX CGG sizing; (ii) 374 negative and 47 positive controls. MS-QMA sensitivity and specificity in controls approached 100% for both sexes. For male probands with no FM detected by standard testing (n = 189), MS-QMA identified abnormal DNA methylation (mDNA) in 4% normal size (NS: < 44 CGGs), 6% grey zone (CGG 45-54) and 12% premutation (CGG 54-199) alleles. The abnormal mDNA was confirmed by AmplideX methylation sensitive (m)PCR and EpiTYPER tests. In contrast, no abnormal mDNA was detected in 89 males with NS alleles from the general population. For females, 11% of 43 probands with NS alleles by the AmplideX sizing assay had abnormal mDNA by MS-QMA, with FM / NS mosaicism confirmed by AmplideX mPCR. FMR1 MS-QMA analysis can cost-effectively screen probands of both sexes for methylation and FM mosaicism that may be missed by standard testing.

Extensive gluteal haematoma after an intracapsular hip fracture in a patient on warfarin.

We describe a case of a patient on warfarin who developed an extensive haematoma after a hip hemiarthroplasty and was successfully treated with embolisation. This case highlights the importance of regular haematology input, careful consideration of a suitable surgical approach, close monitoring of postoperative wounds in patients on warfarin and the emerging role of embolisation.

The position of the centre of the femoral head relative to the midline of the pelvis: a consistent landmark in total knee replacement surgery.

BACKGROUND: Femoro-tibial malalignment in excess of 3° is a recognised contributor of early mechanical failure in total knee replacement (TKR). Knowledge of the location of the centre of the femoral head is a pre-requisite to identification of the mechanical axis of the femur and can facilitate optimal component orientation. We investigated variation in the location of the centre of the femoral head relative to the midline of the pelvis. METHODS: We analysed the pelvic radiographs of 150 patients with unilateral total hip replacements. The perpendicular distance from the centre of the femoral head of the non-operated hip to the centre of pubic symphysis was measured. RESULTS: The mean distance from the centre of the femoral head to the pubic symphysis was 89.2mm (standard deviation, 5.7 mm). Patient height strongly correlated with this distance (r=0.53, p<0.01), as did the diameter of the femoral head (r=0.59, p<0.01). The latter was significantly larger in men than in women (50.9 mm vs. 44.5mm, p<0.01). CONCLUSION: The results demonstrate that the position of the centre of the femoral head has very little variability, irrespective of patient age or body-mass index. If the gender-specific mean femoral head to midline distance is used to estimate the location of the femoral head centre, a line from this point to the centre of the femoral condyles will deviate from the true mechanical axis by no more than 1.5°, in 98% of cases.

Secondary capsular laxity of the hip.

We describe a hip condition with a recognisable pattern of clinical signs and radiological findings thought to result from chronic capsular injury. Between June 2006 and October 2009, ten patients (11 hips), four men and six women, were identified with an abnormality of external rotation at the hip joint. A detailed history and clinical examination was undertaken for each patient. Dynamic magnetic resonance imaging of symptomatic and control hips were evaluated for bony and soft tissue appearances. The relative positions of the femoral head and the acetabulum were assessed through a range of hip rotation. In affected hips, a loss of normal log roll recoil was observed. Three distortions of the iliofemoral ligament were identified on axial MR images; thinning at the lateral insertion of the ligament, attenuation of the iliofemoral ligament most noticeably on maximum external rotation (60º) and the appearance of laxity despite full external rotation. Stability of the hip is dependent on the interaction of bony and soft tissue structures. Hip instability is recognised in dysplasia and is known to lead to premature degeneration of the joint. Chronic capsular injury may destabilise previously asymptomatic hips with subsequent development of pain in young, active patients.