Treatment of pathological fractures of the humerus with a locked intramedullary nail.

OBJECTIVE: The humerus is a common site for metastasis. Intramedullary nail fixation has been reported to be the best form of fixation for this disease but complications occur. This study aimed to assess the use of a new humeral nail to treat pathological fractures and impending pathological fractures of the humerus. METHODS: 29 patients received 31 Austofix locked intramedullary humeral nails: 25 for pathological fractures and 6 for impending fractures; 24 nails were inserted anterograde and 7 retrograde. Cement augmentation was applied in 4 patients, and adjuvant therapy was used in 28 patients. Complications occurred in 12 patients. RESULTS: Fixation failed in 6 patients: 2 due to intraoperative fractures during retrograde nailing, one due to a fracture through screw holes postoperatively, and 3 due to local progression of disease. Difficulty in distal locking of the nail was encountered in 4 patients. Locked intramedullary nailing resulted in a stable humerus in 80% of patients. CONCLUSION: Retrograde insertion of the nail is associated with an increased risk of intra-operative fracture, and disease progression can occur, despite the administration of adjuvant therapy.

IgG-mediated phagocytosis in regenerated splenic tissue.

The risk of severe infections after splenectomy is well established. Operations such as auto-transplantation, splenic artery ligation or partial resection have been advocated for the retention or regeneration of splenic tissue following splenic trauma. The potential of such tissue to protect from infection is unclear. The ability of splenic tissue to phagocytose IgG opsonized syngeneic erythrocytes was measured in rats 6 months following splenectomy and splenic autotransplantation, splenic artery ligation, total or partial splenectomy, and compared with eusplenic controls. In eusplenic and partially splenectomized rats 71% of the label was cleared at 3 h, compared with approximately 50% in rats following total splenectomy, splenectomy and splenic autotransplantation or splenic artery ligation. The autotransplanted and the ligated splenic tissue cleared less than 10% compared with control spleen, but there was no difference between them when clearance was expressed as uptake per gram of tissue. Splenic autotransplants and ligated spleens were small and histologically abnormal, with an increase in the red pulp, significantly less white pulp and marginal zone, and the frequent absence of a central arteriole in the white pulp. The clearance of label was proportional to the amount of red pulp in the tissue, although the red pulp from the regenerated tissues was not as efficient at phagocytosis as control red pulp. The tissue which regenerated following autotransplantation or splenic artery ligation did not result in greater clearance of erythrocytes from the circulation than that which occurred in splenectomized rats.

Antibody responses following splenectomy: implications for the timing of prophylactic vaccination.

Antibody responses are reduced both in the short- and long-term after splenectomy. It is not known if this reduction is more profound in the immediate postoperative period compared to later, and consequently, whether there would be an advantage in delaying prophylactic vaccination to ensure a greater antibody response. To investigate this, the effect of splenectomy on the primary and secondary antibody response to sheep red blood cells (SRBC) injected into the peritoneum (IP) of adult male Porton rats was measured after either splenectomy (Spx), sham splenectomy (Sham), anaesthesia only (Ans) or no procedure at all (Con). There was no difference in the titres of antibody between the Con and the Ans rats. There was no difference in the titres of antibody between the Sham and Spx rats, but both had significantly lower titres than the Con rats. In a separate experiment, rats were immunized 1 month or 1 year after splenectomy or sham-splenectomy. One month after the operation the antibody response of the Sham rats had increased and did not differ from that of Con rats, but in rats which had been splenectomized there was a long-term suppression of the antibody response, which did not improve for at least one year. The results suggest that, in patients requiring splenectomy for trauma and not able to be vaccinated before operation, there may be no advantage in delaying prophylactic vaccination postoperatively.

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

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

Regeneration and phagocytic function of devascularized spleens.

The phagocytic function of normal splenic tissue and of regenerated tissue following splenic artery ligation was investigated in rats using radiolabelled stannous fluoride colloid. Colloidal carbon was used to determine the histological location of phagocytosis within the spleen. Six months after ligation, the median weight of the devascularized spleens was 25% of that of spleens in control rats. Technetium stannous colloid clearance by devascularized spleens was reduced to 10% of normal and 25% when corrected for spleen weight. The colloidal carbon injected intravenously was observed primarily in the marginal zone in both normal and devascularized spleens. Histologically, devascularized spleens contained significantly less white pulp and marginal zone. The splenic tissue which regenerates following ligation does not have the phagocytic ability of normal splenic tissue. This may be due to the decreased regrowth of the lymphoid compartments of the spleen.