Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model.

OBJECTIVES: Experimental studies indicate that non-steroidal anti-inflammatory drugs (NSAIDs) may have negative effects on fracture healing. This study aimed to assess the effect of immediate and delayed short-term administration of clinically relevant parecoxib doses and timing on fracture healing using an established animal fracture model. METHODS: A standardized closed tibia shaft fracture was induced and stabilized by reamed intramedullary nailing in 66 Wistar rats. A 'parecoxib immediate' (Pi) group received parecoxib (3.2 mg/kg bodyweight twice per day) on days 0, 1, and 2. A 'parecoxib delayed' (Pd) group received the same dose of parecoxib on days 3, 4, and 5. A control group received saline only. Fracture healing was evaluated by biomechanical tests, histomorphometry, and dual-energy x-ray absorptiometry (DXA) at four weeks. RESULTS: For ultimate bending moment, the median ratio between fractured and non-fractured tibia was 0.61 (interquartile range (IQR) 0.45 to 0.82) in the Pi group, 0.44 (IQR 0.42 to 0.52) in the Pd group, and 0.50 (IQR 0.41 to 0.75) in the control group (n = 44; p = 0.068). There were no differences between the groups for stiffness, energy, deflection, callus diameter, DXA measurements (n = 64), histomorphometrically osteoid/bone ratio, or callus area (n = 20). CONCLUSION: This study demonstrates no negative effect of immediate or delayed short-term administration of parecoxib on diaphyseal fracture healing in rats.Cite this article: G. A. Hjorthaug, E. Søreide, L. Nordsletten, J. E. Madsen, F. P. Reinholt, S. Niratisairak, S. Dimmen. Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model. Bone Joint Res 2019;8:472-480. DOI: 10.1302/2046-3758.810.BJR-2018-0341.R1.

Long-term outcomes after high-energy open tibial fractures: Is a salvaged limb superior to prosthesis in terms of physical function and quality of life?

PURPOSE: The aim of this study was to describe complication rates and long-term functional outcomes among patients with amputated versus reconstructed limb after high-energy open tibial fractures. METHODS: Patients treated operatively for a high-energy open tibial fracture, classified as Gustilo-Anderson (GA) grade 3, at our hospital in the time period 2004-2013 were invited to a clinical and radiographic follow-up at minimum 2 years after injury. Eighty-two patients with 87 GA grade 3 fractures were included. There were 39 type GA 3A, 34 GA 3B, and 14 GA 3C. RESULTS: The GA 3A reconstruction group had the lowest complication rate and the best long-term outcome scores at mean 5 years (range 2-8 years) after injury. Within the group of GA 3B and 3C fractures, we found no significant differences in long-term outcomes among patients with reconstructed versus amputated limbs. The mean physical component summary score of the SF-36 in the reconstruction versus amputation group was 54.2 (95% CI 46.3-62.1) versus 47.7 (95% CI 32.6-62.2), respectively (p = 0.524), while the mean mental component summary score was 63.7 (95% CI 50.6-71.8) versus 59.2 (95% CI 48.8-68.0), respectively (p = 0.603). On the 6-minute walk test, the reconstruction group walked on average 493 m (95% CI 447-535 m) versus 449 m (95% CI 384-518 m) in the amputation group. The return to work rate was 73% (16 of 22) in the reconstruction group versus 50% (7 of 14) in the amputation group (p = 0.166). The mean patient satisfaction score (VAS 0-100) was 67 (95% CI 67-77) in the reconstruction group versus 65 (95% CI 51-76) in the amputation group (p = 0.795). Regardless of the treatment strategy, the complication rate was high. CONCLUSIONS: Amputation should be considered as a viable treatment option, equal to limb salvage, after high-energy open tibial fracture with severe vascular damage or soft tissue loss.

No difference in time-dependent improvement in functional outcome following closing wedge versus opening wedge high tibial osteotomy: a randomised controlled trial with two-year follow-up.

AIMS: The aim of this prospective randomised study was to compare the time course of clinical improvement during the first two years following a closing or opening wedge high tibial osteotomy (HTO). It was hypothesised that there would be no differences in clinical outcome between the two techniques. PATIENTS AND METHODS: Between 2007 and 2013, 70 consecutive patients were randomly allocated to undergo either a closing or opening wedge HTO. All patients had medial compartment osteoarthritis (OA), and were aged between 30 years and 60 years. They were evaluated by independent investigators pre-operatively and at three and six months, and one and two years post-operatively using the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Oxford Knee Score (OKS), the Lysholm score, the Tegner activity score, the University of California, Los Angeles (UCLA) activity scale and range of movement (ROM). RESULTS: There were no significant differences at any time between the two techniques for any clinical outcome score (p > 0.05). The mean scores for all the systems, except UCLA and Tegner, significantly improved until six months post-operatively (p < 0.001). For some scores, the improvement continued until one and two years. CONCLUSION: This prospective randomised study suggests that there are no differences in the time course of the clinical improvement between the closing and opening wedge techniques for HTO during the first two post-operative years. Patients can expect continued improvement in physical function for between six months and one year after HTO regardless of the technique used. Cite this article: Bone Joint J 2017;99-B:1157-66.

Long-term survival and risk factors for failure of the native hip joint after operatively treated displaced acetabular fractures.

AIMS: Our aim in this study was to describe the long-term survival of the native hip joint after open reduction and internal fixation of a displaced fracture of the acetabulum. We also present long-term clinical outcomes and risk factors associated with a poor outcome. PATIENTS AND METHODS: A total of 285 patients underwent surgery for a displaced acetabular fracture between 1993 and 2005. For the survival analysis 253 were included, there were 197 men and 56 women with a mean age of 42 years (12 to 78). The mean follow-up of 11 years (1 to 20) was identified from our pelvic fracture registry. There were 99 elementary and 154 associated fracture types. For the long-term clinical follow-up, 192 patients with complete data were included. Their mean age was 40 years (13 to 78) with a mean follow-up of 12 years (5 to 20). Injury to the femoral head and acetabular impaction were assessed with CT scans and patients with an ipsilateral fracture of the femoral head were excluded. RESULTS: A total of 36 patients underwent total hip arthroplasty (THA). The overall ten-year survival of the hip joint was 86% (95% confidence interval (CI) 81% to 90%) and the 20-year survival was 82% (95% CI 76% to 87%). Injury to the femoral head and acetabular impaction were the strongest predictors of failure, with the long-term survival rate falling towards 50% in these patients. The survival fell to 0% at three years when both these risk factors were present in patients aged > 60 years. CONCLUSION: The long-term survival of the native hip joint after acetabular fractures was good, but the presence of injury to the femoral head and acetabular impaction proved to be strong predictors of failure, especially in patients aged > 60 years. These patients may be better treated with a combination of open reduction and internal fixation and primary arthroplasty. Cite this article: Bone Joint J 2017;99-B:834-40.

Focussed classification of scapula fractures: failure of the lateral scapula suspension system.

INTRODUCTION: Following an increase in the incidence of scapular fractures and interest in the outcome of their treatment, a basic classification system was developed for ease of use in the emergency setting. It has been expanded to a comprehensive system to allow for more in-depth classification of scapular fractures for clinical research and surgical decision making. It focusses on three specific regions of the scapula: the scapular body, the glenoid fossa and the lateral scapular suspension system (LSSS). This article presents a classification of the LSSS involvement to better characterise the injuries of this region and to emphasise its relevance to evaluation of the position of the scapula, hence the glenoid fossa, and so the centre of rotation of the shoulder joint. METHODS: An iterative consensus and evaluation process comprising an international group of seven experienced shoulder specialist and orthopaedic trauma surgeons was used to specify and evaluate the failure of the LSSS associated with scapula fractures. This was supported by a series of agreement studies. The system considered lack of involvement (S0), incomplete (S1) and complete (S2) failure of the LSSS. The last evaluation was conducted on a consecutive collection of 120 scapula fractures documented by three-dimensional computed tomography (3D CT) reconstruction videos. RESULTS: Surgeons agreed on the involvement/failure of the LSSS in 47% of the 120 cases with an overall Kappa of 0.54. The sample most likely included 70 S0, 29 S1 and 21 S2 cases, where surgeons showed median classification accuracies of 93%, 71% and 80% for these categories, respectively. While two surgeons showed some uncertainty about their classification, the remaining surgeons only failed to identify LSSS failure in <20% of the cases. Kappa coefficients of reliability for classification of incomplete and complete LSSS involvement according to subcategories were 0.85 and 0.82, respectively. CONCLUSION: While LSSS involvement can be reliably identified, its characterisation regarding complexity is problematic even with 3D CT images. The proposed LSSS system is considered clinically relevant and sufficient to further assess its role in treatment-decision processes and outcome prognosis.

Hemiarthroplasty compared to internal fixation with percutaneous cannulated screws as treatment of displaced femoral neck fractures in the elderly: cost-utility analysis performed alongside a randomized, controlled trial.

UNLABELLED: We estimated the cost-effectiveness of hemiarthroplasty compared to internal fixation for elderly patients with displaced femoral neck fractures. Over 2 years, patients treated with hemiarthroplasty gained more quality-adjusted life years than patients treated with internal fixation. In addition, costs for hemiarthroplasty were lower. Hemiarthroplasty was thus cost effective. INTRODUCTION: Estimating the cost utility of hemiarthroplasty compared to internal fixation in the treatment of displaced femoral neck fractures in the elderly. METHODS: A cost-utility analysis (CUA) was conducted alongside a clinical randomized controlled trial at a university hospital in Norway; 166 patients, 124 (75%) women with a mean age of 82 years were randomized to either internal fixation (n = 86) or hemiarthroplasty (n = 80). Patients were followed up at 4, 12, and 24 months. Health-related quality of life was assessed with the EQ-5D, and in combination with time used to calculate patients' quality-adjusted life years (QALYs). Resource use was identified, quantified, and valued for direct and indirect hospital costs and for societal costs. Results were expressed in incremental cost-effectiveness ratios. RESULTS: Over the 2-year period, patients treated with hemiarthroplasty gained 0.15-0.20 more QALYs than patients treated with internal fixation. For the hemiarthroplasty group, the direct hospital costs, total hospital costs, and total costs were non-significantly less costly compared with the internal fixation group, with an incremental cost of €2,731 (p = 0.81), €2,474 (p = 0.80), and €14,160 (p = 0.07), respectively. Thus, hemiarthroplasty was the dominant treatment. Sensitivity analyses by bootstrapping supported these findings. CONCLUSION: Hemiarthroplasty was a cost-effective treatment. Trial registration, NCT00464230.

Radiostereometric analysis of hemiarthroplasties of the hip--a highly precise method for measurements of cartilage wear.

OBJECTIVE: Cartilage wear is a feature of osteoarthritis and rheumatoid arthritis. Precise measurements of wear have been difficult. Cartilage wear caused by an artificial articulating joint surface is a well-known feature of hemiarthroplasties. The aim of this study was to demonstrate that radiostereometric analysis (RSA) may be used for three-dimensional measurements of cartilage wear in hemiarthroplasties of the hip. METHOD: We performed a phantom model study to assess the feasibility of a subsequent clinical trial. We showed that the motion of the prosthetic head relative to the pelvis was not influenced by the orientation of the prosthetic head. Twenty-two patients were randomised to treatment with a cemented or an uncemented hemiarthroplasty for an acute femoral neck fracture. Migration of the prosthetic head into the acetabulum was measured using RSA. RESULTS: A mean migration of the prosthetic head into the acetabulum of 0.62 mm was found at 3 months [95% confidence interval (CI): 0.27-0.97] and a further migration of -0.07 mm at 12 months (95% CI: -0.16-0.32). There were no differences between the groups in prosthetic migration or functional outcome. Between three and 12 months, there was no detectable cartilage wear during the first postoperative year. CONCLUSION: Whether the migration during the first 3 months represents a period of bedding in due to a harder opposite surface remains to be shown. RSA may be used for measurement of cartilage wear in hemiarthroplasties of the hip. This study demonstrates a highly precise method for measurements of cartilage wear.

The early effects of intramedullary reaming of the femur on bone mineral density; an experimental study in pigs.

BACKGROUND AND AIMS: Both fracture and fracture treatment affect bone mineral density (BMD). BMD after standard intramedullary reaming of the femoral cavity and after reaming with a reamer-irrigator-aspirator (RIA) system were studied with the hypothesis that the RIA technique would lead to lower BMD levels. MATERIAL AND METHODS: Dual-energy X-ray absorptiometry (DXA) was performed on the third day after operation with standard intramedullary nailing technique (n = 6) or RIA technique (n = 7) in intact femora of young Norwegian landrace pigs. RESULTS AND CONCLUSION: Significantly lower BMD were found in the mid-shaft and total femur after reaming with the RIA technique compared to the non-operated femur. Traditional reaming technique resulted in significantly higher BMD in the distal -femur. INTERPRETATION: The results of this study indicate that standard reaming increased BMD in the distal femur, suggesting compressive effects on trabecular bone. The RIA technique decreased BMD in the femoral diaphysis and total femur, suggesting removal of trabecular bone. A possible clinical impact of the findings remains to be investigated.

The effect of parecoxib and indometacin on tendon-to-bone healing in a bone tunnel: an experimental study in rats.

Conventional non-steroidal anti-inflammatory drugs (NSAIDs) and newer specific cyclo-oxygenase-2 (cox-2) inhibitors are commonly used in musculoskeletal trauma and orthopaedic surgery to reduce the inflammatory response and pain. These drugs have been reported to impair bone metabolism. In reconstruction of the anterior cruciate ligament the hamstring tendons are mainly used as the graft of choice, and a prerequisite for good results is healing of the tendons in the bone tunnel. Many of these patients are routinely given NSAIDs or cox-2 inhibitors, although no studies have elucidated the effects of these drugs on tendon healing in the bone tunnel. In our study 60 female Wistar rats were randomly allocated into three groups of 20. One received parecoxib, one indometacin and one acted as a control. In all the rats the tendo-Achillis was released proximally from the calf muscles. It was then pulled through a drill hole in the distal tibia and sutured anteriorly. The rats were given parecoxib, indometacin or saline intraperitoneally twice daily for seven days. After 14 days the tendon/bone-tunnel interface was subjected to mechanical testing. Significantly lower maximum pull-out strength (p < 0.001), energy absorption (p < 0.001) and stiffness (p = 0.035) were found in rats given parecoxib and indometacin compared with the control group, most pronounced with parecoxib.

Screw augmentation in displaced femoral neck fractures. Clinical and histological results using a new composite.

We wanted to assess a new technique for augmentation of parallel screws in internal fixation of displaced femoral neck fractures with a bis-GMA-based composite delivered around the screw head. Twenty-one consecutive patients admitted with displaced femoral neck fractures were operated with internal fixation with two parallel Olmed screws augmented with the composite, and followed for 24 months. The composite was introduced through the lumen of the cannulated screws and deposited in the femoral head around the threaded part of the screws. The procedure of augmenting was technically feasible and operation time was on average 33 min. Eleven patients were re-operated due to healing complications within 24 months. There were five redisplacements, four non-unions and two cases of avascular necrosis. Histological examination of four extracted femoral heads showed fragmentation of the composite into small particles with foreign-body response with giant cells and macrophages along with granulation tissue formation and low grade inflammation. The method of augmentation was technically easy, but the failure rate was high and the fragmentation of the composite with inflammatory response found on histology is noteworthy.

Histological evaluation of different biodegradable and non-biodegradable membranes implanted subcutaneously in rats.

Different types of biodegradable membranes have become available for guided tissue regeneration. The purpose of this study was to evaluate histologically three different biodegradable membranes (Bio-Gide, Resolut and Vicryl) and one non-biodegradable membrane (expanded polytetrafluoroethylene/e-PTFE) implanted subcutaneously in rats. Five subcutaneous pouches were created in each of 24 rats. One of the four test membranes was randomly placed in each of the four pouches and one pouch was left empty to serve as a control. Histological evaluation was performed after 4, 10 and 21 days which demonstrated that e-PTFE was well tolerated and encapsulated by a fibrous connective tissue capsule. There was capsule formation around Resolut and Vicryl and around Bio-Gide in the early phase there was a wide inflammatory zone already. e-PTFE and Vicryl were stable materials while Resolut and Bio-Gide fragmented in the early phase. In the late phase Vicryl was surrounded by an increasing amount of multinucleated macrophages and a thin capsule, whilst around Resolut and Bio-Gide a strong foreign body reaction was observed. Also granuloma formation was noted around the fragmented Resolut material in its capsule and a mild inflammatory reaction surrounding Bio-Gide within its thin capsule.

Time-dependent sensory nerve ingrowth into a bone conduction chamber.

We studied time-dependent ingrowth of sensory nerve fibers into a bone defect in a rat bone conduction chamber model. In 10 male Sprague Dawley rats, a titanium chamber was implanted bilaterally in the proximal tibiae, representing an experimental bone defect. To mimic a clinical situation, the chambers were filled with a fresh blood clot After 1, 2, 4, 6 and 8 weeks, 2 rats were fixed in vivo at each time before removal of specimens, and histological and immunohistochemical analyses. We used antisera against protein gene product 9.5, neural growth-associated protein 43/B-50, calcitonin gene-related peptide, and substance P, to locate regenerating sensory nerve fibers in the chamber. During bone defect healing, hematoxylin/eosin sections showed that new bone grew in through the ingrowth openings in the chamber, gradually filling it and replacing the blood clot. At 1 and 2 weeks after implantation, no nerve fibers could be detected. At 4, 6 and 8 weeks, however, small numbers of nerve fibers were seen in 8 of 11 specimens. The nerve fibers were located mainly in the dense fibrous tissue in close proximity to the new bone, and in some cases within the new forming bone. In this chamber model, the periosteum is not in contact with the bone ingrowth openings, and all ingrowing nerve fibers thus originated from the cortical bone, endosteum or bone marrow. We speculated that these late ingrowing sensory nerve fibers may actively participate in bone repair.

Bone mineral density and bone structure parameters as predictors of bone strength: an analysis using computerized microtomography and gastrectomy-induced osteopenia in the rat.

In this study the relationships of bone mineral density (BMD) and bone structure parameters calculated from 2D microtomography images to bone strength were investigated. Femurs from 21 male Sprague Dawley rats were subjected to dual-energy X-ray absorptiometry, computerized microtomography (CmicroT) and either three-point cantilever bending (femoral shaft) or two-point bending compression (femoral neck). Gastrectomy was performed on 12 animals and 9 were sham operated. From the tomograms bone structure analysis was performed using a software routine based on grey level run-length method. Correlations of BMD and bone structure parameters to mechanical parameters were investigated as were differences between the gastrectomized and the control samples. The reductions of BMD between the groups were 21 and 27% in the femoral neck and shaft, respectively. For the shaft, the correlations of BMD to all mechanical parameters were significant and BMD was a consistent predictor of bone strength for cortical bone. However, in the femoral neck where cancellous bone predominates, BMD was weakly correlated only to deflection. A significant correlation between trabecular thickness and neck bone strength was found. Hence, compared to trabecular thickness, BMD was of limited value in predicting bone strength in the femoral neck.

Effect of lifelong nicotine inhalation on bone mass and mechanical properties in female rat femurs.

As tobacco smoking has been identified as a risk factor in the development of osteoporosis, possible deleterious effects of nicotine inhalation on bone mineral density (BMD) and mechanical properties of the femur in female rats were studied. Female Sprague Dawley rats were exposed to nicotine vapour 20 hours a day 5 days a week for 2 years. The nicotine concentration in the inhaled air was kept at a level, giving a plasma nicotine concentration exceeding that of heavy smokers. Throughout the study, the nicotine-exposed rats weighed approximately 10% less than the control rats. At the end of the study the rats were anesthesized and blood was collected by heart puncture for determination of nicotine in plasma. Both femurs were resected and scanned by dual X-ray absorptiometry (DXA). There was no difference in BMD between control rats (n = 7) and nicotine-exposed rats (n = 23) (mean 0.216 +/- 0.021 g/cm(2) and 0. 210 +/- 0.014 g/cm(2), respectively (P = 0.19)). The left femur was used for mechanical testing of the shaft and the neck. No significant difference could be demonstrated in ultimate bending moment, ultimate energy absorbtion, stiffness, or deflection between the two groups. In conclusion, no negative effects of nicotine inhalation on the femurs of female rats were found.

Ethanol and its effects on fracture healing and bone mass in male rats.

Operatively induced, standardized tibia fractures in 42 10-week-old male rats were fixed with intramedullary nails. 21 of the rats were fed liquid containing 15% ethanol. 5 weeks after inducing the fracture, the rats were killed and the total body bone mineral density (BMD) was analyzed with the DEXA technique, and the mechanical properties of the fractured and the unfractured tibiae as well as the ipsi- and contralateral femoral shaft and femoral neck were tested. The rats given a liquid containing 15% ethanol were found to have significantly lower total BMD and total calcium than the controls. We also found a significantly lower bending moment and bending stiffness both in the fractured and unfractured tibiae among rats fed on ethanol. The energy absorption until refracture was less in rats fed on ethanol. Posttraumatic osteopenia was present, as judged by the mechanical tests of the ipsilateral femoral shaft and the femoral neck in all animals. There was no difference in this respect between the animals fed on ethanol and the controls. We found that ethanol disturbs bone metabolism which reduces the mechanical properties of the tibiae and femora of rats, but the healing process of an induced tibial shaft fracture was not affected.

No adverse effects of clodronate on fracture healing in rats.

Clodronate was administered daily 28 days before and after an experimental tibial fracture in 35 male rats, and the effect on fracture healing and posttraumatic bone loss was studied. 5 groups were tested. The clodronate/clodronate group received clodronate in daily doses of 10 mg/kg body weight for 28 days before being subjected to a standardized fracture of the right tibia, and during the fracture healing period of 28 days. The clodronate/saline group received clodronate before fracture and saline during the healing period. The saline/clodronate group received saline before and clodronate after fracture. The saline/saline group received saline only, while the control group served as unfractured, untreated controls. After 28 days of fracture healing, the tibias were evaluated with dual energy x-ray absorptiometry, and tested mechanically in a 3-point ventral bending test. Bone mineral content and bone mineral density were approximately 30% higher in the groups receiving clodronate during the experiment, compared to the untreated groups. The weight and cross-sectional area of the fracture callus were equal in all groups. Whether clodronate was administered before the fracture, after the fracture or both, did not affect the bone mineral. Ultimate bending moment, energy absorption, stiffness and deflection were not significantly different between the groups. Our findings suggest that clodronate increases bone mineral both when given before and after a tibial shaft fracture, without affecting fracture healing at 28 days.

Fracture healing and callus innervation after peripheral nerve resection in rats.

The effects of femoral and sciatic nerve resection on fracture healing and innervation of the fracture callus were studied using a stable fracture model. In 34 rats the right tibia was subjected to a standardized closed fracture and stabilized with a modular intramedullary nail. In half of the animals, resection of 1 cm of the femoral and sciatic nerves was performed (nerve resection group), whereas the other animals had sham operations (sham group). To avoid unequal load-bearing between the two groups, all fractured hindlimbs were immobilized in a plaster of Paris cast. The trial was terminated after 5 weeks of fracture healing. Callus size was scored radiographically, and bone mineralization was measured by 85-strontium incorporation. Seven rats from each group had immunohistochemical examination for neural regeneration and ingrowth. Antisera for protein gene product 9.5, neurofilaments, neural growth associated protein 43/B-50, calcitonin gene related peptide, and substance P were used. The mechanical properties of the healing fractures were recorded in a three-point cantilever bending test. After 5 weeks, the normally innervated, fractured tibias had regained approximately 50% strength compared with the unfractured side, in comparison with only 20% in the animals that had nerve resection. Although the fracture calluses were mechanically weaker, they were significantly larger in the nerve resection group, indicating defects in tissue composition or organization rendered by the nerve injury. The mineralization rate, as measured by 85-strontium incorporation, was the same in the two groups. However, the nerve resection did not provide complete denervation but changed the innervation pattern of the healing fracture, as the density of sensory nerve fibers immunostaining for substance P and neurofilaments was less in the group with femoral and sciatic nerve resection. The results suggest that intact innervation is essential for normal fracture healing because nerve injury induced a large, but mechanically insufficient, fracture callus.

Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw.

OBJECTIVE: To compare the results after operative treatment of unstable per- and subtrochanteric fractures with the Gamma nail, compression hip screw (CHS), or dynamic hip screw with a laterally mounted trochanteric stabilizing plate (DHS/TSP). DESIGN: Prospective. PATIENTS: One hundred seventy patients with unstable trochanteric femoral fractures surviving six months after operation. Eighty-five patients were randomized to treatment with the Gamma nail (n = 50, Gamma group) or the compression hip screw (n = 35, CHS group) and compared with a consecutive series of eighty-five patients operated with the dynamic hip screw with a laterally mounted trochanteric stabilizing plate (DHS/TSP group) MAIN OUTCOME MEASUREMENTS: Radiographs were analyzed for fracture classification, evaluation of fracture reduction, implant positioning, later fracture dislocation, and other complications. Pre- and postoperative functional status of the patients were recorded, with a minimum of six months follow-up. RESULTS: Eighteen percent of the patients in the Gamma group, 34 percent in the CHS group, and 9 percent in the DHS/TSP group suffered significant secondary fracture dislocation during the six months follow-up, leading to a varus malunion, lag screw cutout, or excessive lag screw sliding with medialization of the distal fracture fragment. Two patients (4.0 percent) in the Gamma group suffered an implant-related femoral fracture below the nail, and one had a deep infection. The reoperation rates were 8.0 percent in the Gamma group, 2.9 percent in the CHS group, and 5.9 percent in the DHS/TSP group. All but one fracture in the Gamma and CHS groups and two fractures in the DHS/TSP group healed within six months. Approximately three-fourths of the patients had returned to their preoperative walking ability after six months, with a trend toward better functional outcome in the DHS/TSP group. Use of a TSP reduced the secondary lag screw sliding as compared with the conventional CHS, without affecting fracture healing. CONCLUSION: The TSP may be an aid in the treatment of these difficult fractures because the problem with femoral shaft fractures using the Gamma nail is avoided and the medialization of the distal fracture fragment frequently associated with the CHS is prevented.

Film processing and the environment. Reducing pollution, water consumption, and costs.

PURPOSE: X-ray film processing is associated with pollution from photo chemicals and from the water used to rinse the film. We tested a new processing system that was aimed at reducing both environmental pollution and costs through the use of solid photo chemicals and recirculation of the rinsing water. MATERIAL AND METHODS: Before and after the installation of new mixers for the solid chemicals and a system for recirculating the rinsing water, we measured: water consumption, processor function quality, image quality, archivability, and the waste-silver content in the rinsing water. RESULTS: After the installation of a simple system for recirculating the rinsing water, there was an 88% reduction in water and film consumption as shown in the amount of water/m2 film that was used. At the same time, the release of silver-contaminated rinsing water directly into the sewers was stopped. Image quality remained unchanged. Archivability was assessed at more than 100 years. The solid photo chemicals and specially designed mixers proved efficient and provided a stable image quality of high standard. It was thus possible to reduce the risk of pollution from the transportation, storage and handling of liquid chemicals. CONCLUSION: A simple recirculation system for the rinsing water would significantly reduce water consumption and eliminate contamination of the environment by silver. The on-site preparation of photo chemicals proved viable and reduced the costs of film processing.