No Major Differences in Recovery After Hip Fracture Between Home-Dwelling Female and Male Patients.

BACKGROUND: Studies comparing recovery of men and women after hip fracture have reported conflicting results, some reporting worse recovery in male patients, while others found no differences between genders. METHODS: Recovery was compared in 105 male and 433 female patients with hip fractures and in age-matched groups of patients 50 years or older, who were home-dwelling and received similar rehabilitation. Residential status, walking ability, hip pain and activities of daily living function were recorded at admission and 4 and 12 months postoperatively, along with mortality and re-operations. RESULTS: No differences were observed between men and women 4 and 12 months postoperatively regarding residential status (p = 0.181 vs p = 0.883), mortality rates (p = 0.232 vs p = 0.880) or total activities of daily living scores (p = 0.546 vs p = 0.435). Walking ability was better among male patients prefracture (p < 0.001) and 4 and 12 months after fracture (p < 0.001, p = 0.031, respectively). In age-matched pair analysis, no differences were found regarding mortality, residential status, walking ability, or ADL score. Cox regression analysis identified mortality risk factors as being age, prefracture ADL score, American Society of Anesthesiologists score 4-5 and place of rehabilitation. Sex was not mortality risk factor. INTERPRETATION: Home-dwelling male and female patients had similar courses of recovery from hip fracture, although there were singular differences in specific activities of daily living functions and postoperative pain. There were no differences in mortality, even when prefracture characteristics were considered. Mortality was higher among older patients and who had high American Society of Anesthesiologists scores and low prefracture activities of daily living scores.

Costs after hip fracture in independently living patients: a randomised comparison of three rehabilitation modalities.

OBJECTIVE: To evaluate costs and cost-effectiveness of physical and geriatric rehabilitation after hip fracture. DESIGN: Prospective randomised study (mean age 78 years, 105 male, 433 female) in different rehabilitation settings: physically oriented (187 patients), geriatrically oriented (171 patients), and healthcare centre hospital (control, 180 patients). MAIN MEASURES: At 12 months post-fracture, we collected data regarding days in rehabilitation, post-rehabilitation hospital treatment, other healthcare service use, number of re-operations, taxi use by patient or relative, and help from relatives. RESULTS: Control rehabilitation (4945,2€) was significantly less expensive than physical (6609.0€, p=0.002) and geriatric rehabilitation (7034.7€ p<0.001). Total institutional care costs (primary treatment, rehabilitation, and post-rehabilitation hospital care) were lower for control (13,438.4€) than geriatric rehabilitation (17,201.7€, p<0.001), but did not differ between control and physical rehabilitation (15659.1€, p=0.055) or between physical and geriatric rehabilitation ( p=0.252). Costs of help from relatives (estimated as 30%, 50% and 100% of a home aid's salary) with physical rehabilitation were lower than control ( p=0.016) but higher than geriatric rehabilitation ( p=0.041). Total hip fracture treatment costs were lower with physical (36,356€, 51,018€) than control rehabilitation (38,018€, 57,031€) at 50% and 100% of salary ( p=0.032, p=0.014, respectively). At one year post-fracture, 15D-score was significantly higher in physical rehabilitation group (0.697) than geriatric rehabilitation group (0.586, p=0.008) and control group (0.594, p=0.009). CONCLUSIONS: Considering total costs one year after hip fracture the treatment including physical rehabilitation is significantly more cost-effective than routine treatment. This effect could not be seen between routine treatment and treatment including geriatric rehabilitation.

Combination of radiograph-based trabecular and geometrical parameters can discriminate cervical hip fractures from controls in individuals with BMD in non-osteoporotic range.

Majority of hip fractures occur in individuals with bone mineral density (BMD) in non-osteoporotic range. This suggests that factors other than BMD are associated with increased fracture risk in these individuals. The aim of this study was to investigate the combined ability of radiograph-based trabecular and geometrical parameters to discriminate cervical hip fractures from controls in individuals with non-osteoporotic BMD. A total of 39 postmenopausal females with non-pathologic cervical hip fracture were recruited to the study. Nineteen of the fracture patients (48.7%) had non-osteoporotic BMD and they constituted the fracture group. The control group consisted of 35 BMD-matched non-osteoporotic females. Several geometrical and trabecular parameters were extracted from plain pelvic radiographs, and their combined ability to discriminate fracture patients from controls was studied using a receiver operating characteristics (ROC) analysis. Significant differences in several radiograph-based geometrical and trabecular parameters were found between the fracture patients and controls, whereas no statistically significant difference in BMD was observed (p=0.92) between the groups. Area under the ROC curve was 0.993 (95% CI 0.977-1.008) for the combined multiple regression model, which included both trabecular and geometrical parameters as explanatory factors. Here, the sensitivity of 100% was achieved with the specificity of 94%. In a cross-validation of the model, 94.4% of the fracture patients, and 94.1% of the controls were classified correctly. The combination of radiograph-based trabecular and geometrical parameters was able to discriminate the cervical hip fracture cases from controls with similar BMD, showing that the method can provide additional information on bone structure and fracture risk beyond BMD.

BMD T-score discriminates trochanteric fractures from unfractured controls, whereas geometry discriminates cervical fracture cases from unfractured controls of similar BMD.

UNLABELLED: The ability of bone mineral density (BMD) to discriminate cervical and trochanteric hip fractures was studied. Since the majority of fractures occur among people who are not diagnosed as having osteoporosis, we also examined this population to elucidate whether geometrical risk factors can yield additional information on hip fracture risk beside BMD. The study showed that the T-score criterion was able to discriminate fracture patients from controls in the cases of trochanteric fractures, whereas geometrical measures may discriminate cervical fracture cases in patients with T-score >-2.5. INTRODUCTION: Low bone mineral density (BMD) is a well-established risk factor for hip fracture. However, majority of fractures occur among people not diagnosed as having osteoporosis. We studied the ability of BMD to discriminate cervical and trochanteric hip fractures. Furthermore, we examined whether geometrical measures can yield additional information on the assessment of hip fracture risk in the fracture cases in subjects with T-score >-2.5. METHODS: Study group consisted of postmenopausal females with non-pathologic cervical (n = 39) or trochanteric (n = 18) hip fracture (mean age 74.2 years) and 40 age-matched controls. BMD was measured at femoral neck, and femoral neck axis length, femoral neck and shaft cortex thicknesses (FNC and FSC), and femoral neck-shaft angle (NSA) were measured from radiographs. RESULTS: BMD T-score threshold of -2.5 was able to discriminate trochanteric fractures from controls (p < 0.001). Seventeen out of 18 trochanteric fractures occurred in individuals with T-score -2.5. Within these non-osteoporotic cervical fracture patients (N = 19) and non-osteoporotic controls (N = 35), 83.3% were classified correctly based on a model including NSA and FNC (p < 0.001), area under the receiver operating characteristics curve being 0.85 for the model, while it was only 0.56 for BMD alone. CONCLUSIONS: The study suggests that the risk of trochanteric fractures could be discriminated based on a BMD T-score <-2.5 criterion, whereas cervical fracture cases would remain under-diagnosed if solely using this criterion. Instead, geometrical risk factors are able to discriminate cervical fracture cases even among individuals with T-score >-2.5. For cervical and trochanteric fractures combined, BMD and geometric measures independently contributed to hip fracture discrimination. Our data support changing from T-score <-2.5 to a more comprehensive assessment of hip fracture etiology, in which fracture type is also taken into account. The findings need to be confirmed with a larger sample, preferably in a prospective study.

Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients.

The aim of this prospective matched-pair (age, sex, fracture type, residential status, and walking ability at fracture) study was to analyse the short-term outcome after Gamma nail (GN) and dynamic hip screw (DHS) fixation, focusing especially on functional aspects (Standardised Audit of Hip Fractures in Europe [SAHFE] hip fracture follow-up forms), reoperations, and mortality. Both groups consisted of 134 patients. DHS and GN groups did not differ significantly with respect to location of residence at 4 months or returning to the prefracture dwelling (78% vs. 73%, P = 0.224). The change in walking ability at 4 months compared to prefracture situation was better in the DHS group (p = 0.042), although there was no difference in the change of use of walking aids. The frequency of reoperations during the first year was somewhat lower in the DHS group (8.2% vs. 12.7%, p = 0.318). Mortality was lower in the DHS group both at 4 months (6.0% vs. 13.4%, p = 0.061) and 12 months (14.9% vs. 23.9%, p = 0.044). Although walking ability was better and mortality lower in the DHS group, both methods are useful in the treatment of trochanteric femoral fractures.

Articular bone loss treated with a staged method using bone cement or beads as a spacer and subsequent autografting: a report of two cases.

Fractures with bone loss are rare. Cancellous autografting is commonly used to treat metaphyseal and diaphyseal traumatic bone loss, but little is known about the applicability of this method to the treatment of intra-articular bone loss. We report two cases of articular bone loss that were treated with a staged method of using antibiotic-impregnated bone cement in one case and beads in another as spacer in the primary phase and cancellous autografting in second-stage surgery.

Endostatin inhibits endochondral ossification.

BACKGROUND: Angiogenesis is essential for the replacement of cartilage by bone during skeletal growth and regeneration. Vascular endothelial growth factor-A (VEGF-A) is a key regulator of angiogenesis whereas endostatin, a potent inhibitor of endothelial cell proliferation and migration, is a natural antagonist of VEGF-A. The regulatory role of these peptides in angiogenesis and bone formation was investigated using adenoviral gene delivery of VEGF-A and endostatin in a mouse ectopic ossification model. METHODS: Bone formation was induced in the hamstring muscles of adult mice with native bone morphogenetic protein (BMP) extract implemented in gelatine gel together with VEGF-A and endostatin recombinant adenoviral vectors. The mice were sacrificed 1, 2, and 3 weeks after the operation and ectopic bone formation was followed radiographically and histologically. RESULTS: Significant bone formation was induced by BMP extract in all treatment groups. VEGF-A stimulated and endostatin prevented the formation of FVIII-related antigen-positive vessels as well as the number of cartilage-resorbing chondroclasts/osteoclasts. Endostatin alone or in conjugation with VEGF-A reduced bone formation. Excess of VEGF-A stimulated and endostatin reduced bone formation, respectively, at the 3-week time point. CONCLUSIONS: Our findings indicate that endostatin retards the cartilage phase in endochondral ossification which subsequently reduces bone formation in our experimental model. We conclude that bone growth and healing, which share features with ectopic bone formation, may be regulated by endostatin.

RhBMP-7 accelerates the healing in distal tibial fractures treated by external fixation.

External fixation of distal tibial fractures is often associated with delayed union. We have investigated whether union can be enhanced by using recombinant bone morphogenetic protein-7 (rhBMP-7). Osteoinduction with rhBMP-7 and bovine collagen was used in 20 patients with distal tibial fractures which had been treated by external fixation (BMP group). Healing of the fracture was compared with that of 20 matched patients in whom treatment was similar except that rhBMP-7 was not used. Significantly more fractures had healed by 16 (p=0.039) and 20 weeks (p=0.022) in the BMP group compared with the matched group. The mean time to union (p=0.002), the duration of absence from work (p=0.018) and the time for which external fixation was required (p=0.037) were significantly shorter in the BMP group than in the matched group. Secondary intervention due to delayed healing was required in two patients in the BMP group and seven in the matched group. RhBMP-7 can enhance the union of distal tibial fractures treated by external fixation.

Treatment of subtrochanteric fractures. A comparison of the Gamma nail and the dynamic hip screw: short-term outcome in 58 patients.

The aim of this non-randomised prospective study was to evaluate the short-term outcome of Gamma nail and dynamic hip screw (DHS) fixation in the treatment of subtrochanteric hip fractures due to low-energy trauma in the elderly. All of the 1,624 femoral hip fractures in 1,511 patients of the Oulu Hospital, aged over 49 years, were prospectively registered from 1991-1999 using special forms. Seventy-three (4.5%) of the fractures were subtrochanteric. After exclusions, 58 patients constituted the final study group. Of these, 43 were treated with Gamma nails and 15 with DHS. Background factors before the fracture, complications, reoperations and functional parameters at 4 months were recorded using standardised forms. Intraoperative and hospital data were collected from patient records. The Seinsheimer fracture types IIIA, IIC and V were the most common fracture patterns when the Seinsheimer classification system was used, and Fielding II and AO 31A3.3, respectively, were the most common types in the Fielding and AO classification system. There were four (9%) intraoperative complications in the Gamma nail group as compared to none in the DHS group. On the other hand, postoperative complications were more common in the DHS group (27%) than in the Gamma nail group (7%). We recognised a correlation between certain fracture types and the likelihood of typical intra- or postoperative complications or difficulties with both devices: In Gamma nailing, difficulty in closed reduction as well as the rate of open reduction and the use of supplementary fixation were most frequent in the Seinsheimer IIC fractures. It is also noticeable that all of the postoperative device failures and fracture displacements of the DHS group occurred in the Seinsheimer type IIIA category. Detailed fracture classification is essential for the choice of the fixation device, and the present study confirms the presumption that, despite the perioperative problems associated with Gamma nailing, this technique may be preferable to plate fixation for specific fracture types with medial cortical comminution, such as Seinsheimer type IIIA.

Hip fracture treatment in Oulu--one-year survey with four-month follow-up.

BACKGROUNDS AND AIMS: The standardized forms of the Standardized Audit of Hip Fractures in Europe (SAHFE) are aimed for the evaluation of hip fracture treatment in different hospitals and countries. The purpose was to evaluate and characterize a cohort of hip fracture patients with these forms and to evaluate their value in quality control. MATERIAL AND METHODS: The non-pathological hip fractures in patients over 49 years of age treated in the Oulu University Hospital were prospectively recorded during a one-year period using SAHFE forms. RESULTS: There were 238 (52 male and 186 female) patients with a mean age of 78 (50-102) years. Fifty-nine percent of the patients were admitted from their own homes. Fifty-seven percent were able to walk alone outdoors and 48% could walk without walking aids before the fracture. A hundred and fifty patients had cervical fractures and 88 trochanteric fractures. The most frequent treatment of cervical fractures was Austin-Moore hemiarthroplasty (68%) and that of trochanteric fractures Gamma nail fixation (86%). At four months after the fracture, 50% lived in their own homes, 33% could walk alone outdoors and 13% could walk without any aids. Thirty-two percent had no pain in the hip. The overall mortality at four months was 17.6% and that of the operated patients 16.2%. The reoperation rate was 8.5%. CONCLUSION: SAHFE forms were very useful in the evaluation of the quality of the hip fracture treatment.

Impact of deep infection after hip fracture surgery on function and mortality.

Our aim was to evaluate the impact of deep wound infection after hip fracture surgery on functional outcome and mortality. Two thousand, two hundred and seventy-six consecutive surgically treated patients with non-pathological fractures, aged over 50 years (mean age 78.3 years), were followed up prospectively. The 29 patients who had deep infection (rate 1.3%) and who received revision surgery were compared with controls without infection, matched for age, sex, residential status at fracture, fracture type, treatment method and walking ability. When the functionality of hip fracture patients was evaluated four months after the primary operation, the patients with deep wound infection had impaired walking ability (P=0.039) and required walking aids, including wheelchairs, more often than the control patients (48% vs 20.8%, P=0.022). At four months, the mean duration of hospitalization at the primary hospital was significantly longer for the cases than the controls (P<0.001). Diabetes was more common in the patients with deep infection (P=0.038). Staphylococcus aureus was the most commonly isolated micro-organism, and it was associated with higher one-year mortality (57%) than the other bacteria (14.3%, P=0.014); the overall mortality of the infected patients and controls was 34.5% and 24.1% at one year, respectively (P=0.508). In conclusion, deep infection after a hip fracture operation impairs short-term functional outcome and slightly increases mortality, with an excess mortality rate of 10.4%.

Evaluation of 238 consecutive patients with the extended data set of the Standardised Audit for Hip Fractures in Europe (SAHFE).

PURPOSE: The aim of this paper is to introduce the extended data set inquiries of the Standardised Audit of Hip Fractures in Europe (SAHFE) and to report our experiences of its use. METHOD: The extended SAHFE data set was applied to 238 consecutive patients (mean age 78.4 (50 - 102) years, 52 males, 186 females) aged over 50 years with non-pathological fractures of the hip. The extended data set contains 95 questions concerning the patient's abilities prior fall and at follow-up, detailed background factors, concomitant diseases, additional details of the injury, treatment, fracture type and reduction and complications. RESULTS: Thirty-nine percent of the fractures occurred at home and 38% in a hospital. Thirteen percent of the cervical fractures were non-displaced (Garden 1 & 2) and half of the trochanteric fractures intertrochanteric two-part fractures (A11 - A13). The mean Garden alignment index evaluated from antero-posterior roentgenograms changed from the preoperative 144 degrees to the postoperative 168 degrees and that from lateral projections from 144 degrees to 171 degrees , respectively. Most of the patients (89%) had associated diseases, especially cardiovascular conditions. The patients' functioning was significantly impaired at four months compared with the preoperative situation according to the ADL score. The need for social support and assistance had increased, respectively. A total of 63% of the surgeries were delayed for more than 24 hours. Low molecular weight heparin was given to every patient for thromboembolic prophylaxis and 92% received antibiotic prophylaxis. Urinary tract (21%) and chest infections (7%) were the most common complications. The deep infection rate was 2.5%. CONCLUSION: The extended SAHFE data set is useful and makes it possible to study in more detail the background and outcome factors of hip fractures in a standardized manner.

Brain atrophy evaluated by computed tomography in independent and institutionalized hip fracture patients.

PURPOSE: To examine if there is an association between brain computed tomography (CT) findings and place of residence in a series of hip fracture patients. METHOD: The CT scans taken immediately after hip fracture of 215 patients (mean age 81.6 years) living in their own homes or otherwise independently (home-dwelling group) and 95 patients (mean age 82.5 years) permanently institutionalized (institutionalized group) were analysed. RESULTS: The institutionalized patients had significantly more cortical cerebral (frontal, p = 0.004; temporal, p = 0.007; parietal, p < 0.001) and central cerebral (third ventricle width, p < 0.001; frontal horn width, p < 0.001; midbody width, p < 0.001) atrophy than the home-dwelling ones. This was also true of atrophy in the white-matter (WM) area (p < 0.001). The institutionalized patients also had more atrophy of the cerebellar hemisphere (atrophy of the cerebellopontine angle cistern, p = 0.002, greater fourth ventricle width, p = 0.020). No significant difference was seen in the incidence of brain infarcts. CONCLUSIONS: Hip fracture patients living in institutions have more brain atrophy than those living independently. The brain atrophy may be one factor in the multiple mechanism underlying their institutional admission.

Four or twelve months' follow-up in the evaluation of functional outcome after hip fracture surgery?

BACKGROUND AND AIMS: As a rule, follow-up for at least one year is recommended for fracture studies. This is considered the shortest reliable interval. Still, in the case of hip fractures of the elderly, shorter follow-up might be more practical, since the life expectancy of these patients is often short. The aim of this study was to see if a short four months follow-up period would be acceptable in hip fracture surveys. MATERIAL AND METHODS: Information on 196 consecutive non-pathological hip fracture patients aged 50 years or over (mean 79 years) was collected using a standardised hip fracture audit concentrating on functional measurements at admission and at four and twelve months' follow-ups. RESULTS: 167 patients were alive at four months and 152 and at one year. The patients who died between four and twelve months had poorer functional capacity in the four- month evaluation than those who survived one year. The analysis of repeated measures, including only the patients alive at the last follow-up, showed that residential status, use of walking aids and 6 out of 10 and ADL variables (bathing, toileting, shopping, household activities, doing laundry, banking) did not change significantly. Walking ability and the rest 4 ADL variables (dressing, eating, food preparation, use of transportation) improved and pain decreased. CONCLUSIONS: Due to high mortality and age-related deterioration of functioning, no steady state i.e. "final result" is ever reached after hip fracture in the elderly. Four-month follow-up is justified as the shortest possible period, because the socioeconomically most important variable, i.e. place of living, and most of the ADL functions do not change significantly after that.

Gamma irradiation and ethylene oxide in the sterilization of native reindeer bone morphogenetic protein extract.

BACKGROUND AND AIMS: For human use, it is necessary to sterilize bone morphogenetic proteins (BMPs), in order to reduce the risk of infections and associated complications. We compared the effects of ethylene oxide and gamma irradiation in the sterilization of native reindeer BMP extract with regard to bone induction in the Balb/C mouse thigh muscle pouch model. MATERIALS AND METHODS: BMP extract, sterilized with ethylene oxide gas (Steri-Vac 4XL, temperature 29 degrees C, exposure time 4 h, ethylene oxide concentration 860 mg/l), or gamma irradiation at doses of 3.15 MRad was administered in implants containing 5 or 10 mg of BMP extract with collagen carrier. Non-sterilized collagen implants served as controls. New bone formation was evaluated based on the incorporation of Ca45 and radiographically three weeks after implantation. RESULTS: The collagen was not able to induce new bone visible in radiographs. The mean Ca45 incorporation in the gamma sterilized group containing 5 mg of BMP extract was 30% (p = 0.04) and that containing 10 mg of BMP extract was 60% (p = 0.02) higher than seen in the corresponding ethylene oxide sterilized groups. The mean new bone areas were 45% higher in the gamma sterilized groups than in the corresponding ethylene oxide sterilized groups, but the differences were not significant. The mean optical density of new bone in the gamma sterilized group containing 5 mg of BMP extract was 75% (p = 0.00) and in that containing 10 mg of BMP extract was 70% (p = 0.00) higher than seen in the corresponding ethylene oxide sterilized groups. CONCLUSION: Native reindeer BMP extract is more sensitive to the effects of ethylene oxide gas sterilization than gamma irradiation. These results suggest that gamma irradiation is recommendable for the sterilization of BMP extracts.

The effect of different mineral frames on ectopic bone formation in mouse hind leg muscles induced by native reindeer bone morphogenetic protein.

INTRODUCTION: Bone morphogenetic proteins (BMPs) require carrier material for slow release and framing material for osteoconduction. MATERIALS AND METHODS: The effect of a frame on early bone formation induced by partially purified native reindeer BMP in composite implants containing 3 mg of BMP, type IV collagen and tricalcium phosphate (TCP/Col/BMP) or hydroxyapatite (HA/Col/BMP) or biphasic tricalcium phosphate-hydroxyapatite (TCP/HA/Col/BMP) or biocoral (NC/Col/BMP) was evaluated using a mouse hind leg muscle pouch model. Collagen with native reindeer BMP (Col/BMP) and corresponding implants without native reindeer BMP served as controls. Evaluation was done by incorporation of 45Ca, radiographically and histologically 3 weeks after the implantation. RESULTS: None of the implants without native reindeer BMP were able to induce new bone visible on radiographs. The area of new bone formation in the Col/BMP (p=0.026) and TCP/HA/Col/BMP (p=0.012) groups was significantly greater than in the TCP/Col/BMP group. The optical density of the new bone area was significantly greater in the TCP/HA/Col/BMP group than in the TCP/Col/BMP (p=0.036) or Col/BMP (p=0.02) groups. 45Ca incorporation was many times greater in all the groups containing native reindeer BMP than in the corresponding groups without BMP. In the Col/BMP (p=0.046) and TCP/HA/Col/BMP (p=0.046) groups, 45Ca incorporation was significantly greater than in the TCP/Col/BMP group. No significant differences were found in any parameters between HA/Col/BMP and NC/Col/BMP groups and the other BMP-containing groups. CONCLUSIONS: Hydroxyapatite, biocoral and biphasic tricalciumphosphate-hydroxyapatite are equally good as framing material for native reindeer BMP, while tricalciumphosphate is somewhat worse. Osteoinduction of native reindeer BMP works well with collagen alone.

Hip fractures in Finland--a comparison of patient characteristics and outcomes in six hospitals.

BACKGROUND AND AIMS: To compare six Finnish hospitals for the quality of treatment of hip fractures and to obtain information for the development of care. MATERIAL AND METHODS: Data of 1179 consecutive hip fracture patients (about 200 patients per hospital) was collected prospectively, using similar standardized forms and focusing on background factors and the four-month functional outcome. RESULTS: There were significant differences between the hospitals in patient characteristics (age, place of residence, walking ability, use of walking aids, morbidity and type of fracture) and in the unadjusted outcome variables at four months' follow-up (place of residence, mobility, use of walking aids and pain in injured hip). After adjustment for baseline characteristics, there was a significant difference in the post-fracture walking ability between the centres but no significant differences in post-fracture place of residence. Unadjusted mortality did not vary between the centres, but adjustment resulted in significant differences. The most marked difference in surgical methods between the hospitals was seen in the use of either sliding hip screw or Gamma Nail for trochanteric fractures, but this difference was not reflected in the results of multivariate analysis. CONCLUSIONS: We found minor differences in mobility and mortality between the participating hospitals, and these might serve them as a stimulus for improving their standard of good practice. Continuous quality improvement by repeating the audit cycle is recommended in order to reach and then improve the prevalent standards in the care of hip fracture patients. Confounding factors should be adjusted when comparing the medical centres treating hip fractures, and the evaluation of the results should be multidimensional.

Influence of ethylene oxide sterilization on the activity of native reindeer bone morphogenetic protein.

We studied the effects of ethylene oxide sterilization (Steri-Vac 4XL, temperature 29 degrees C, exposure time 4 h 10 min, ethylene oxide concentration 860 mg/l) on the osteoinductivity of partially purified native reindeer bone morphogenetic protein (BMP) in a hind leg muscle pouch model of male NMRI mice. BMP was administered in implants containing 3 mg in a collagen carrier. Implants without sterilization and without BMP served as controls. New bone formation was evaluated based on the calcium yield, radiographic and histological examination 3 weeks after implantation. The implants without BMP were not able to induce new bone visible in radiographs. In the sterilized BMP group, the mean area of new bone was 35% ( p=0.004) and density 32% ( p=0.000) smaller than in the nonsterilized group. Calcium yield was 20% lower in the sterilized group than in the nonsterilized group, but this difference was not significant ( p=0.22). It was many times lower in the group without BMP than in the above-mentioned groups ( p=0,001). We conclude that ethylene oxide gas sterilization reduces the bone-forming activity of native reindeer BMP by one third.

Functional ability after hip fracture among patients home-dwelling at the time of fracture.

The aim of the study was to assess the change in function and residential status four months after hip fracture in patients over 50 years of age and living independently at home at the time of fracture. All consecutive hip fracture patients treated at Oulu University Hospital during 1989--1999 were followed up. Data collection was done on standardized hip fracture forms, which were filled in at admission and at four months postoperatively. The forms included demographic data, place of residence, locomotor ability, use of walking aids, data on the fracture and its treatment, hospital stay, place of discharge and pain. At four months, 16.0% of the men and 14.3% of the women were permanently institutionalized. Preoperatively, 81.1% of the patients had been able to walk out of doors either alone or accompanied, while at 4 months, less than half of the patients (149 men, 391 women) were able to do so. Two thirds of the hip fracture patients had been able to walk without walking aids before the fracture, the corresponding proportion being one fifth at four months after the fracture. Cumulative mortality at 4 months was 9.9%, being higher among the male (15.5%, n=53) than the female patients (7.9%, n=75). The original study population was also divided into two subgroups operated at different period of time (1989--92 and 1993--99), the functional results seemed to improve with time. Hip fracture leads to the institutionalization of every seventh patient able to live at home at the time of fracture and impairs markedly one's functional capacity. To restore the pre-fracture status as well as possible and to reduce the burden of the consequences of hip fracture, it might be beneficial to evaluate and improve the existing rehabilitation system.

New bone formation induced by injection of native reindeer bone morphogenetic protein extract.

BACKGROUND AND AIMS: Bone morphogenetic proteins (BMPs) are usually administered with a solid framing material during open surgery. In some instances, percutaneous administration of injectable BMP would be preferable. We tested the new bone-forming activity of injectable native reindeer BMP extract in the Balb/C mouse thigh muscle pouch model. MATERIALS AND METHODS: The injectable implants contained 6 mg of native reindeer BMP extract and either physiological saline (NaCl/BMP) or collagen (Gel/BMP). Corresponding implants without BMP served as controls. New bone formation was evaluated based on incorporation of Ca45 and radiographically three weeks after the injection into the mouse thigh muscles. RESULTS: None of the injections without BMP were able to induce new bone visible in radiographs, whereas the injections with BMP induced new bone effectively. There were no significant differences in the area of new bone (p = 0.247) and its density (p = 0.739) between the NaCl/BMP and Gel/BMP groups. Ca-45 incorporation was multifold in the NaCl/BMP and Gel/BMP groups compared to the controls (p = 0.000). No significant differences in Ca-45 incorporation (p = 0.739) between the NaCl/BMP and Gel/BMP groups were observed. CONCLUSION: Our results suggest that BMP can be administered percutaneously, and that collagen and physiological saline are equally good carriers of injectable implants of native reindeer BMP.