Early functional results after hemiarthroplasty for femoral neck fracture: a randomized comparison between a minimal invasive and a conventional approach.

BACKGROUND: A minimal invasive approach for elective hip surgery has been implemented in our institution in the past. It is widely hypothesized that implanting artificial hips in a minimal invasive fashion decreases surgical trauma and is helpful in the rehabilitation process in elective hip surgery. Thereby geriatric patients requiring emergency hip surgery also could theoretically benefit from a procedure that involves less tissue trauma. METHODS: Sixty patients who sustained a fractured neck of femur were randomly assigned into two groups. In the minimal invasive arm, the so called "direct anterior approach" (DAA) was chosen, in the conventional arm the Watson-Jones-Approach was used for implantation of a bipolar hemi-arthroplasty.Primary outcome parameter was the mobility as measured by the four-item-Barthel index. Secondary outcome parameters included pain, haemoglobin-levels, complications, duration of surgery, administration of blood transfusion and external length of incision. Radiographs were evaluated. RESULTS: A statistically significant difference (p = 0,009) regarding the mobility as measured with the four-item Barthel index was found at the 5th postoperative day, favouring the DAA. Evaluation of the intensity of pain with a visual analogue scale (VAS) showed a statistically significant difference (p = 0,035) at day 16. No difference was evident in the comparison of radiographic results. CONCLUSIONS: Comparing two different approaches to the hip joint for the implantation of a bipolar hemi-arthroplasty after fractured neck of femur, it can be stated that mobilization status is improved for the DAA compared to the WJA when measured by the four-item Barthel index, there is less pain as measured using the VAS. There is no radiographic evidence that a minimal invasive technique leads to inferior implant position. LEVEL OF EVIDENCE: Level II therapeutic study.

Fractured neck of femur--internal fixation versus arthroplasty.

BACKGROUND: Surgery is the treatment of choice for fractured neck of femur. For middle-aged patients (aged ca. 40 to 65), there is considerable debate over the indications for arthroplasty or internal fixation. The choice of surgical technique varies widely from one region to another. In this article, we discuss the main criteria that should be used in making this decision. METHODS: We selectively reviewed the literature on the diagnosis and treatment of fractured neck of femur, including the current guideline of the German Society for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU) and recent findings from the field of health services research. RESULTS: The treatment of middle-aged patients with dislocated fractures should be based on rational decision-making. The patient's level of activity before the accident should be judged in terms of his or her previous mobility, independence in daily activities, and mental status. Internal fixation is recommended if the fracture can be adequately repositioned, the bone is of good quality, and there is no evidence of osteoarthritis. Fractures that are more than 24 hours old should be treated with total hip arthroplasty. Hemiprostheses are appropriate for very old patients. Physically frail, bedridden, and/or demented patients should undergo internal fixation of the fracture. For non-displaced or impacted fractures, functional treatment (i.e., prophylactic securing of the fracture with screws or nails) is indicated. Rapid diagnosis and a short time in bed before surgery lower the rate of complications. Internal fixation with preservation of the femoral head should ideally be performed within the first 6 hours of trauma, and within the first 24 hours at most. CONCLUSION: Despite the increasing scarcity of resources, treatment should still be based on well-founded clinical guidelines. Minimally invasive surgery enables better function in the early postoperative phase and can thereby lower complication rates. An interdisciplinary concept for the postoperative care of elderly patients also has a major effect on the outcome.

Is the Wave Plate Still a Salvage Procedure for Femoral Non-union? Results of 75 Cases Treated with a Locked Wave Plate.

OBJECTIVE: To analyse the results of the treatment of aseptic femoral non-unions using a singular locked implant. DESIGN: Consecutive case series. SETTING: A level-1 trauma center with a high number of specialist referrals. PATIENTS: The study is based on a consecutive series of patients with prospective data evaluation. From 1993 to 2003, 75 patients were treated with a wave plate. All patients had persistent non-union of the femoral shaft without clinical or laboratory signs of infection and previous unsuccessful attempts to treat the non-union. INTERVENTION: The method of treatment was standardized and included a lateral approach, cancellous bone hip grafting, osteosynthesis with a wave-shaped plate (PPF) and polyaxial locking screws as well as the application of a gentamicin-PMMA chain. MAIN OUTCOME MEASUREMENTS: Time to achieve union, rate of implant failure and number of remaining nonunions after treatment. A total of 75 patients had full follow-up and were included in the study. RESULTS: The union of the fracture was found in 64 patients after the initial procedure. In eight cases a second procedure was performed to achieve union in the form of a second bone graft because of a delay in callus formation. The mean time to union was 7.3 months with a range from 3 to 19 months. The implant failed in three cases accounting for 4% of the total. CONCLUSION: The locked wave plate offers a further reliable treatment for complex aseptic femoral non-unions.

Delayed and non-union of the humeral diaphysis--compression plate or internal plate fixator?

In a retrospective study, two groups of patients with delayed or non-union of the humeral diaphysis were compared. In group A, a 4.5-mm low-contact dynamic compression plate (LCDCP) was used for internal fixation and in group B, an internal plate fixator with locked screws was used. In all patients autologous bone grafting was performed. Group A consisted of 14 patients (mean age 38.9 years) and group B consisted of 19 patients (mean age 54.3 years). The mean duration of the delayed or non-union was 9.3 months (range 3-26 months) in group A and 24.8 months (range 3-216 months) in group B. In group A an average of 1.1 (range 0-2) previous operations had been performed, and in group B an average of 1.6 (range 0-4). One primary nerve palsy was diagnosed in group A and six in group B. Although the patients of group B were older, had longer-lasting non-unions, more previous operations and more severe initial injuries, only in group A was there a hardware failure due to osteoporosis which required re-osteosynthesis. All other patients showed bony consolidation without further operations. The LCDCP and the internal plate fixator both showed high consolidation rates, but we feel that the internal plate fixator may be the more reliable implant, especially in patients with poor bone stock.