Hip fracture treatment: outcome and socio-economic aspects. A one-year survey in a Belgian University Hospital.

Between October 1, 1997 and September 30, 1998, 201 consecutive hip fractures in patients over the age of 50 were registered according to the SAHFE (Standardised Audit of Hip Fractures in Europe) protocol. The mean age was 81.3 years; 75% were females, more than 40% were admitted from an institution and fewer than 10% were completely fit. Almost 60% of the fractures occurred in the trochanteric region while less than 40% were intracapsular. All fractures but one were operated on, according to a standardised protocol. More than half the patients were treated with a dynamic hip screw, more than 30% with a cemented biarticulated hemiarthroplasty and fewer than 15% with cannulated screws. The mean admission time in the orthopedic department was 18.7 days and was poorly correlated with the type of surgery or with the place to which the patients were discharged. After hospitalisation, most patients admitted from an institution went back to that institution. More than one-third of the patients admitted from their home went back home but over 40% used rehabilitation facilities. After four months, 32 patients had died, 27 were lost to follow-up and six had been reoperated. Of the independent patients, at least 24% were institutionalised and more than 60% lived at home. Although hip fractures in the elderly are expensive and debilitating, adequate operative treatment and rehabilitation can reduce costs by limiting the hospital stay, lowering reoperation rates and by favouring reintegration into their prefracture surroundings.

Bipolar versus total hip arthroplasty in the treatment of avascular necrosis of the femoral head in young patients.

The authors evaluate medium-term results of bipolar and total hip arthroplasty as a treatment for avascular necrosis of the femoral head. Between 1990 and 2000, 57 hips (45 patients) were treated with a bipolar (BHA: 37 hips) or total hip arthroplasty (THA: 20 hips) depending on the radiographic and macroscopic aspect of the acetabulum. At surgery, all patients were under 65 years of age (average: 45.09 years). All had the same cementless hydroxylapatite coated femoral stem inserted through an anterolateral approach. The BHA were followed during a mean of 4.49 years. One BHA was lost to follow-up. Seven out of 36 hips (19.44%) were considered failures: three due to a poor functional result (Harris Hip Score (HHS) <70) and four which needed conversion to THA for groin pain. Two hips were revised for periprosthetic fracture. Twenty BHA (55.56%) had a good or excellent result (HHSY80). The THA were followed for a mean of 4.32 years. One THA was lost to follow-up. Four out of 19 hips (21.05%) were considered as failures. Three due to a poor functional result (HHS<70) and one which needed cup revision for recurrent dislocation. Fifteen THA (78.95%) had a good or excellent functional result (HHSY80). BHA as a treatment of avascular necrosis of the femoral head in young patients preserves bone stock for later revisions and can lead to excellent results. But the outcome seems less predictable than after THA. Groin pain associated to BHA can be treated successfully with conversion to THA if necessary. (Hip International 2002; 2: 142-9).

Split coronal fractures of the lumbar spine. Treatment by posterior internal fixation and transpedicular bone grafting.

The clinical and radiological results of 12 patients with a split coronal vertebral fracture were analysed with minimum follow-up of 24 months. All patients were treated operatively with an AO internal spinal fixator and transpedicular bone grafting. The operation was supplemented with posterior bone grafts in 4 patients. All fractures healed without marked deformity. There were no vertebral body pseudarthroses. There were no neurological or vascular injuries due to the placement of pedicle screws or to transpedicular bone grafting. 10 patients, had excellent or good results.

Static and dynamic roentgenographic analysis of ankle stability in braced and nonbraced stable and functionally unstable ankles.

Patients suffering from functional ankle instability were selected based on a structured interview. Talar tilt was measured using supine ankle stress roentgenographs and standing talar tilt was measured using erect ankle stress roentgenographs. A digital roentgenocinematographic analysis of a 50 degrees ankle sprain simulation was performed to measure dynamic talar tilt and inversion distance between two video images (inversion speed). A significant decrease in pathologic supine talar tilt in unstable ankles was found in the braced compared with the nonbraced situation (talar tilt = 13.1 degrees versus 4.8 degrees with brace). The talar tilt with the brace after activity was still significantly lower than the initial value without the brace. The standing talar tilt of unstable ankles was shown to be significantly lower with the orthosis than without (standing talar tilt = 16.6 degrees versus 12.0 degrees with brace). Roentgenocinematographic evaluation of ankle sprain simulation showed that the mean dynamic talar tilt during simulated sprain decreased significantly in the braced ankles compared with the nonbraced ankles (dynamic talar tilt = 9.8 degrees versus 6.4 degrees braced). A significant decrease in the digital measurement of inversion distance (from 110.6 pixels to 92.4 pixels) was observed in the total sample of 39 ankles during the initial high-speed phase of the simulated sprain. The brace significantly slows down the inversion speed.

Objective roentgenologic measurements of the influence of ankle braces on pathologic joint mobility. A comparison of 9 braces.

The stabilizing effect of external support (taping and nine different ankle braces) was tested in a total of 220 functionally unstable ankles. A standard surface EMG controlled stress Roentgen test protocol was used, measuring talar tilt (TT) without support and with tape bandage or brace. Different levels of TT restraining by external support could be identified. Tape bandage and two braces had a highly significant influence on the talar tilt. The mean TT without support was decreased by using from 13.4 degrees to 4.9 degrees, by using one brace to 4.8 degrees and by using another brace to 5.9 degrees. These two braces are effective for protection during functional treatment. A classification into three grades of effectiveness is proposed. It is concluded that the stabilizing influence offered by bandages and braces should be measured before using the external support as a treatment device for acute ankle sprain and as a reliable protection against sprain injuries in daily living and sports.

Atlantoaxial rotatory fixation. A case report and proposal of a new classification system.

Atlantoaxial rotatory fixation (AARF) remains a relatively rare finding. A case of AARF is reported and the existing Fielding and Hawkins classification is reviewed. Furthermore a new classification system is proposed.

Clinical and radiographic evaluation of Wilson osteotomy for hallux valgus.

Thirty-two Wilson osteotomies (26 patients) were evaluated after a mean follow-up time of 20 months. According to the classification of Bonney and MacNab, there were 90% good and excellent results. There was no correlation between the patient's appraisal of the result and the clinical result based on objective, functional, and radiographic data. The occurrence of metatarsalgia or callosities did not correlate with shortening or angulation. If there was a tendency to recurrence, there was a greater loss of correction with a longer duration of follow-up. In addition, patients over 50 seemed to have a greater tendency to recurrence than younger patients.

Proximal femoral replacement prosthesis for salvage of failed hip arthroplasty: complications in a 2-11 year follow-up study in 19 elderly patients.

We reviewed 19 elderly patients who underwent revision total hip arthroplasty with a proximal femoral replacement prosthesis for aseptic loosening and severe proximal femoral bone loss. The mean interval from initial hip replacement to revision arthroplasty was 8 (2-20) years. The mean age of the patients was 78 (63-87) years. 2 patients died within 2 years postoperatively and 1 patient was lost for follow-up evaluation. The remaining 16 patients were assessed clinically and radiographically after a mean follow-up period of 5 (2-11) years. All patients had local pain relief, but they all needed a crutch or another walking aid. According to the Merle d'Aubigne hip-rating scale there were no excellent results, 1 very good, 8 good, 5 fair, 2 poor and no bad results. 4 patients had an intraoperative fracture, 7 had a dislocation, 2 had a deep infection, and 3 patients had progressive loosening of the screws fixing the greater trochanter to the femoral component. Our series demonstrates that revision of a failed hip prosthesis, using a proximal femoral replacement prosthesis, presents complex problems.

Treatment of isolated distal ulnar shaft fractures with below-elbow plaster cast. A prospective study.

In a prospective study 52 patients with an isolated fracture of the distal ulna were treated with a below-elbow plaster cast. The histories of 46 patients were reviewed after a mean follow-up of 3.5 years (ranging from 10 months to 7 years). Forty-three fractures united. There were two non-unions. One fracture displaced while in the plaster, so that there was no longer any bone contact between the fragments. The fracture was consequently treated by open reduction and internal fixation. The type of fracture, the initial displacement (all fractures had bone contact) or the initial angulation (maximum 10 deg) was not found to influence the final clinical results. Below-elbow plaster cast appeared to produce satisfactory results in 89% of the patients.

Posteromedial tibial plateau fractures. Operative treatment by posterior approach.

Seven patients treated by open reduction through a single posterior approach and internal fixation with an AO T-plate for displaced posteromedial fracture of the tibial plateau were reviewed. Followup ranged from 1 to 10 years, and all patients had excellent or good results, and there were no complications caused by the method of treatment.

Prosthesis for the treatment of metastatic bone disease of the hip: effects of radiotherapy.

Twenty-eight patients with metastatic involvement of the proximal femur were all treated by resection and prosthetic replacement. A large femoral prosthetic component was routinely fixed with polymethylmetacrylate bone cement. Local radiotherapy was delivered preoperatively in two patients and postoperatively in seven patients. Postoperative pain relief according to Habermann et al off excellent in 81% and good in 15% of the patients. The functional results according to the hip-rating scale of Merle d'Aubigné were rated as excellent in 19%, very good in 22% and good in 22% of the hips. The prognosis for survival was superior in those patients with a preoperative Karnofsky performance status index of more than 60 points (p < 0.01) and in those patients without postoperative pulmonary complications (p < 0.01). The radiographs of the eighteen patients surviving three months or longer showed formation of a new bony envelope around the femoral prosthetic component in 11 cases (61%) and bone remodelling of the distal femur in 12 cases (67%). When analyzed according to local radiotherapy these radiographic changes occurred only if no local radiotherapy had been delivered to the femur (p < 0.01).

Loosening of a noncemented porous-coated anatomic femoral component in Gaucher's disease. A case report and review of literature.

There are few reports of experiences with hip arthroplasty in patients with Gaucher's disease. Review of the literature shows a high rate of loosening after any type of arthroplasty. The clinical, roentgenographic and histopathological findings of a porous-coated hip arthroplasty in Gaucher's disease necessitating revision after 5 years are reported. Because we found typical lipid-laden Gaucher cells at the bone prosthesis interface we support the hypothesis that loosening in Gaucher's disease is due to continued Gaucher cell proliferation and erosion of bone. Loosening seems to be related to the disease and not to a specific type of prosthetic component.

Primary bipolar arthroplasty or total hip arthroplasty for the treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients.

One hundred independently mobile patients over the age of 75 who had an unstable intertrochanteric or subtrochanteric fracture were treated with primary prosthetic replacement. In all patients a cemented femoral component with diaphyseal support was used. A bipolar arthroplasty was performed in 91 patients and a total hip arthroplasty in 9 patients because of associated coxarthrosis. The functional results according to the Merle d'Aubigné hip rating scale were excellent, very good or good in 78% of the hips. The dislocation rate of 44.5% in the patient group who underwent total hip arthroplasty was significantly higher than the 3.3% in those who had bipolar arthroplasty. Associated with the dislocations was a much higher incidence of pressure sores and pulmonary complications. Adverse effects on the femoral side included 4 cases with progressive loosening of the screws used to fix the greater trochanter to the femoral component, 1 fracture of the distal femur and 1 pseudarthrosis of the bone envelope surrounding the femoral component.

Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient.

Failure of internal fixation in hip fractures can lead to difficult problems, especially in elderly patients. At the intertrochanteric or subtrochanteric level a prosthesis with diaphyseal support is one of the solutions to this problem. In 12 patients an endoprosthesis was performed for failed internal fixation. The mean age at the time of initial fracture fixation was 79 years (range: 61 to 94 years). The mean time from initial fracture fixation to failure and salvage by an endoprosthesis was 6 months (range: 5 days to 19 months). Eleven patients could be reviewed clinically and radiographically after a mean follow-up time of 32 months (range: 4 months to 7 years). The functional results were satisfactory considering the age of the patients. The current series shows that endoprosthesis might be considered as a valuable method in the salvage treatment of failed internal fixation of a subtrochanteric or intertrochanteric hip fracture.

[Prosthetic replacement for pathological fractures of the proximal end of the femur: total prosthesis or bipolar arthroplasty?]. / Remplacement prothétique pour fracture pathologique de l'extrémité supérieure du fémur: prothèse totale ou prothèse intermédiaire?

INTRODUCTION: The purpose of this prospective study was to present our experience with bipolar or total hip arthroplasty in 28 consecutive cases of metastasis of the intertrochanteric and subtrochanteric area. MATERIALS AND METHODS: Twenty-eight patients with metastatic involvement of the proximal femur underwent either bipolar or total hip arthroplasty. Proximal femoral resection and prosthetic replacement with a massive component was routinely performed. RESULTS: The postoperative morbidity rates for dislocation and pressure sores were significantly lower (p < 0.05) in the bipolar arthroplasty group. Postoperative pain relief according to Habermann was excellent in 81.5 per cent and good in 14.8 per cent of the patients. The functional results according to the hip rating scale of Merle d'Aubigné were rated as excellent in 19 per cent, very good in 22 per cent and good in 22 per cent of the hips. The prognosis for survival was superior in patients with a preoperative Karnofsky performance status index of more than 60 points (p < 0.01) and in patients without postoperative pulmonary complications (p < 0.01). New bone formation around the femoral prosthetic component occurred in 11 (61 per cent) of the 18 patients surviving three months or longer. This bone formation did not affect the clinical results. In the current series pain relief as well as postoperative walking ability were comparable in both groups but the dislocation rate was significantly lower (p < 0.05) with bipolar arthroplasty. CONCLUSION: We recommend bipolar arthroplasty rather than total hip arthroplasty in patients with a preoperative Karnofsky performance status index of more than 60 points if bone disease of the acetabulum is not evident on standard radiographs and if during operation the acetabular cartilage appears normal.

Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient.

Nine elderly patients were treated by salvage hip arthroplasty following failed internal fixation of an intertrochanteric or subtrochanteric hip fracture. The mean age at time of fracture was 79 years (range 67-94 years). The mean interval from initial fracture fixation to conversion arthroplasty was 7 months (range 5 days to 19 months). One 84-year-old patient died 6 weeks postoperatively from a pulmonary infection. The remaining eight patients were assessed clinically and roentgenographically after a mean follow-up period of 41 months (range 4-85 months). The functional results, rated according to the Merle d'Aubigné hip rating scale, were excellent in one patient, very good in four patients, good in two patients, and fair in one patient. Serial roentgenographic analysis showed new bone formation around the extramedullary part of the femoral component in all these patients and bone remodelling of the diaphyseal part of the femur in all patients. The preservation of the functional continuity of the abduction apparatus during surgery and the early walking with full unrestricted weight-bearing made possible by the arthroplasty are considered to be the major contributing factors to these results.

The rate of recurrence of traumatic anterior dislocation of the shoulder. A study of 154 cases and a review of the literature.

We have reviewed the history of 154 primary, traumatic dislocations of the shoulder in order to determine the risk of recurrence. We found a recurrence rate of 68% in patients under the age of 20, after a follow-up period of 1-9 years (average 4.5 years). There was a highly significant difference (p < 0.0001) in the recurrence rate of patients under, and above, 30 years of age. Twenty per cent of the patients had a concurrent minor fracture at the shoulder with 2 out of 39 of the recurrent cases (5%) and 29 of the 115 non-recurrent cases (25%); this is also a significant difference (p < 0.01). Neither the need for general anaesthesia at primary injury nor the occupation of the patient was a relevant factor in the final outcome of the dislocation. Four nerve injuries were encountered (3%), with no severe sequelae at follow-up. The young patient with no concurrent fracture at the time of the primary shoulder dislocation has a high risk of recurrence.

Cemented acetabular reconstruction with the Müller support ring. A minimum five-year clinical and roentgenographic follow-up study.

In a previous study, the results of cemented acetabular reconstruction with a Müller support ring were reported after a mean follow-up period of 40 months. The current report concerns a minimum five-year follow-up study of the same 43 patients. Two early failures at four months and at 17 months were related to poor surgical technique. The latest overall functional results, according to the Merle d'Aubigné rating scale, were excellent, very good, or good in 81.82% of the hips: a drop from 86.67% since the previous report. Sequential roentgenographic analysis demonstrated a high incidence of nonprogressive radiolucencies at the cement-bone interface. These nonprogressive radiolucencies did not correlate with the overall functional results. The progression of a radiolucency at the cement-bone interface, however, or the appearance of radiolucencies around the screw threads, always resulted in clinical failure.

Surgical treatment of acute type-V acromioclavicular injuries in athletes.

In a prospective study, 18 consecutive athletes with an acute type-V acromioclavicular sprain were treated with a coracoclavicular repair using a double velour Dacron graft. All patients were reviewed after a mean follow-up period of 6 years (range: 2-9 years). At follow-up, 12 patients (66.7%) showed a good or excellent result according to the Imatani evaluation system, and six patients (33.3%) demonstrated a fair or poor result according to the same system. Loss of reduction was encountered in eight shoulders (44.4%) despite an initial anatomical reduction. No correlation was seen between the overall scores at follow-up and the degree of residual dislocation, between the overall scores and the presence of coracoclavicular calcifications or ossifications, between the overall scores and the development of post-traumatic arthritic changes, or between the overall scores and the presence of osteolysis of the distal clavicle.