We have performed a prospective review of 590 consecutive patients treated for a displaced intracapsular femoral neck fracture with a Thompson hemiarthroplasty. 113 patients had the prosthesis cemented, 477 had no cement. The outcome at 12 months was obtained for every patient still alive as regards to pain, mobility, re-operation rate and residential status. There was no significant difference between the 2 groups as regards pain (p = 0.482), decrease in mobility or re-operation rate (p = 0.168). The main determination of poor outcome was increasing age at time of injury and whether the patient was already in institutional care at the time of the injury. The use of cement had no bearing on outcome. This study is of clinical interest because patients who have undergone uncemented hemiarthroplasty have been shown to have similar out come to cemented hemiarthroplasty in terms of function. In addition possible but preventable complications associated with cementing can be minimized. We now believe there is no primary indication to cement the Thompsons hemiarthroplasty in this group of patients. There have been smaller studies looking at this, but we believe this to be the largest and most comprehensive to date.
We aim to assess the value of patellofemoral Computed Tomography in assessing patients with anterior knee symptoms. Anterior knee symptoms are often due to patellar malalignment. Plain axial radiography or (CT) can be used to investigate these abnormalities. We have evaluated the use of patellofemoral CT scanning in 63 patients and compared the CT findings with the patients’ symptoms. We compared patellar centralisation and patellar tilt angle with the symptom described for each of 126 knees. No difference could be detected in the CT appearances of affected and unaffected knees in those patients with unilateral symptoms (all patients have both knees scanned). A significant association between maltracking and osteoarthiritic changes was demonstrated.
To evaluate the results of management of urological injury and the impact on final outcome in patients with pelvic fractures. Out of 554 patients with pelvic fractures, 39 (7%)(8 female) were identified with urinary tract injuries. The mean age of the patients was 30.9 yrs (range 15–71) and the mean ISS was 12.9 (range 9–22). Seven (18 %) had upper tract injury, 6 (15.4 %) had extraperitoneal bladder rupture, 9 (23.1 %) had intraperitoneal rupture, 3 (7.6 %) had bladder neck injury and 14 (35.9 %) had urethral injury. Timing of urological intervention, complications and long term result in terms of incontinence, stricture and sexual dysfunction were assessed. All patients were assessed based on Orthopaedic, urological and the Euroqol (EQ5D) generic health questionnaire and compared to age and sex matched control group of 47 patients with similar pelvic injuries and ISS but no urological injury. The mean follow up period was 2.3 years. Upper urinary tract injuries: All were managed non-operatively and had a uniformly good outcome except one patient who had a traumatic renal vein thrombosis and required nephrectomy. Lower tract injuries: 14 out of 15 patients with bladder rupture had a repair of bladder within 24 hours of arrival at our center. One with a small extraperitoneal tear was managed nonoperatively. Three patients reported failure of erection. Two were managed by immediate repair (day 1 and day 2) and had normal continence. One repair was delayed due to delay in transfer and was done on the 4th day. He developed faecal and urinary incontinence and loss of sexual function. Thirteen males had urethral injury. Three patients had a primary urethrostomy for a gap defect and two of these developed erectile dysfunction. Two were referred late to our center and were managed by continent urinary diversion. The rest had a catheter railroaded to maintain alignment of the two urethral ends and delayed repair was done for three patients. One patient in this group had sexual dysfunction while 5 developed a stricture. We found no significant difference between the study and the control group in the outcome on comparing patients with upper tract and bladder injuries but the urethral injury group had a poorer result in all 5 parameters of the EQ5D. Upper tract and bladder injuries do not add significant morbidity compared to the control group. In contrast urethral injuries significantly affected the outcome after pelvic fracture in terms of general health and return to normal function.
The U-shaped sacral fracture is a fracture pattern poorly recognized, that is not included in the standard classification of sacral fractures. These fractures are significant as they represent spino-pelvic dissociation, have a high incidence of neurological complications and information regarding modern treatment options is sparse. A number of authors have reported isolated cases or small series of patients with this type of fracture, although none explicitly note the bilateral vertical element that makes them U-shaped and represents spino-pelvic dissociation. We present four patients with U-shaped sacral fractures. All patients were polytraumatised patients of whom three had jumped from a height in suicide attempts illustrating the high energy required to produce this fracture. Three patients had ilio-sacral screw fixation, supplemented in one with instrumentation from the lumbar spine to the iliac crest. The other had sacral laminectomy with bony stabilization by instrumentation from the lumbar spine to the iliac crest without ilio-sacral screw fixation. No complications were encountered as a result of fixation. The fixation devices used essentially represent the local expertise that is available. The ilio-sacral screw technique is minimally invasive and appears to provide satisfactory fixation in our limited experience. However as fracture deformity often involves rotation of the upper sacrum, the use of a single screw may not provide adequate support against the deforming forces or allow reduction of the fracture. Additional ilio-sacral screws will provide some rotational control of the sacral fragment if their safe insertion is possible, if not then the forces should probably be neutralized by an additional device from L5 to the pelvis. The role of sacral decompression is unclear but may be appropriate in the presence of neurological deficit and a severely compromised sacral canal. These are complex, rare injuries. We recommend their referral to a specialized pelvis/spinal unit for definitive management.
The clinical features, investigation, treatment and outcome of two adults with fibrogenesis imperfecta ossium are described. In this rare acquired disorder of bone, normal lamellar collagen is replaced by structurally unsound collagen-deficient tissue, which leads to extreme bone fragility and ununited fractures. Transmission microscopy and SEM showed striking ultrastructural changes in bone structure and mineralisation. Both patients had monoclonal IgG paraproteins in the plasma and one excreted monoclonal lambda light chains in the urine. No abnormal plasma cells were found in the bone marrow and there was no evidence of amyloid deposition in the tissues. In both patients initial treatment with 1 alpha-hydroxycholecalciferol appeared to be ineffective, but in one, repeated courses of melphalan and corticosteroids over three years together with 1 alpha-hydroxycholecalciferol produced striking clinical and histological improvement. The findings in these and other patients strongly suggest that paraproteinaemia is an integral feature of fibrogenesis imperfecta ossium, and this needs further investigation.