Morbidity and mortality following fractures of the femoral neck and trochanteric region: analysis of risk factors.

A retrospective review of casenotes with patient review at 3 years was carried out of 405 patients who had surgery for fracture of the femoral neck (including the trochanteric region). The operative management consisted of either internal fixation (61%), hemiarthroplasty (38%), or total arthroplasty (1%). Medical complications developed in 30% of patients; surgical complications developed in 14%. The mortality rate was greater for the first 9 months after operation, but thereafter approached the rate found in the general population (matched for age and sex). Followup 3 years postoperatively recorded 50% of patients still alive. Factors associated with death within the first postoperative year included increasing age, male sex, and the presence of dementia or congestive cardiac failure. Of the survivors, 55% described unlimited range of mobility but 32% reported only poor mobility (progressive dementia being the most common cause). Factors associated with poor mobility were increasing age, female sex, placement in an institution, and the presence of dementia or cerebrovascular insufficiency. Transfer to the specialist rehabilitation ward postoperatively was associated with significantly improved survival and mobility.

Orthopaedic pitfalls.

When presented with an orthopaedic problem, rational management cannot occur without a reasonable diagnosis. Such a diagnosis can only be made by listening to the patient's history, and by examining him with a clear knowledge of important and relevant anatomy. Such relevant anatomy has been outlined in order to make sense of the symptom complexes in: --arm pain --knee pain --back pain without sciatica --back pain with sciatica The behaviour of collagen, which takes three weeks to heal and at least three weeks more to strengthen, is the basis of rational treatment of ligamentous injuries. Advice is given on specific situations to avoid the pitfalls of treatment which is too much, too little, too late or too soon.

Experimental production of forward dislocation in the human cervical spine.

Entire human cadaveric cervical spines with the basiocciput were subjected to load in a compression apparatus to simulate the clinical situation of forward dislocation. The movements were recorded by lateral cineradiography. Vertical load was measured by a potentiometric transmitter synchronised with each frame of the cineradiograph. The lower part of the spine was flexed and fixed, and the upper extended and free to move forward. Vertical compression then produced bilateral dislocation of the facets without fracture. If lateral tilt or axial rotation occurred as well, a unilateral dislocation was produced. The maximum vertical load was only 145 kilograms, and coincided with the rupture of the posterior ligament and capsule and the stripping of the anterior longitudinal ligament, but this occurred before dislocation. The low vertical load indicates a peculiar vulnerabiity of the cervical spine in this position and correlates well with the minor trauma often seen in association with forward dislocation.

Osteogenesis imperfecta. A clinical and biochemical study of a generalized connective tissue disorder.

The clinical features of 62 patients with the diagnosis of osteogenesis imperfecta, a generalized connective tissue disorder, have been reviewed. The structural polymeric collagen of the skin has been examined by biochemical and histological methods in 21 of these patients and in two further patients with osteogensis imperfecta who died soon after birth. The results provide evidence of heterogeneity within this group of patients. Three main types of disorder are recognizable: those patients with dominantly inherited mild bone disease, blue sclerae and low amounts of polymeric collagen; those who occur sporadically, with severe bone disease, normal coloured sclerae and polymeric collagen of reduced stability; and occasional infants with severe bone disease who die at birth or soon after and whose polymeric collagen appears to be abnormal. It is speculated that these differences could be due to distinct abnormalities of collagen metabolism.

A new look at osteogenesis imperfecta. A clinical, radiological and biochemical study of forty-two patients.

In a clinical, radiological and biochemical study of forty-two patients from Oxford with osteogenesis imperfecta, it was found that patients could be divided simply into mild, moderate and severe groups according to deformity of long bones. In the severe group (seventeen patients) a family history of affected members was uncommon and fractures began earlier and were more frequent than in the mild group (twenty-two patients); sixteen patients in the severe group had scoliosis and eleven had white sclerae; no patients in the mild group had white sclerae or scoliosis. Radiological examination of the femur showed only minor modelling defects in patients in the mild group, whereas in the severe group five distinct appearances of bone (thin, thick, cystic and buttressed bones, and those with hyperplastic callus) were seen. The polymeric (structural) collagen from skin was unstable to depolymerisation in patients in the severe group, but normal in amount, whereas the reverse was found in the mild group. This division according to long bone deformity may provide, a basis for future research more useful than previous classifications.

Instability of polymeric skin collagen in osteogenesis imperfecta.

The structural polymeric collagen of the skin of 19 patients with osteogenesis imperfecta has been examined. In those with severe bone disease, who often have white sclerae, this collagen fraction is less resistant to depolymerization than that of age-matched controls, though the total amount is normal. In patients with less severe bone disease, whose sclerae are usually blue, the polymeric collagen may have normal stability but the total amount is reduced. These results suggest defective cross-linking of collagen in severe osteogenesis imperfecta.