The purpose of this study was to evaluate functional outcome following supracondylar femur fractures using patient-based outcome measures.

Patients having sustained supracondylar femur fractures between 1990 and 2004 were identified from the fracture databases of two level-one trauma centres. Three patient-based outcome measures, the Short Form-36 (SF-36) Version two, the Short Musculoskeletal Functional Scale (SMFA), and the Lower Extremity Functional Scale (LEFS) were used to evaluate functional outcome. Each patient’s medical record was also reviewed to obtain information regarding potential predictors of outcome, including age, gender, fracture type (AO classification), presence of comorbidities, smoking status, open vs. closed fracture, and occurrence of complications. Univariate and multivariate models were then used to identify significant predictors of outcome, as reflected in the SMFA bother and dysfunction scores.

Sixty-one patients (thirty-five males and twenty-six females) with an average age (at time of injury) of 53 ± 18 years consented to participate. The average length of follow-up was 64 ± 34 months from the time of injury. Mean SF-36 V2 scores were lower than Canadian population norms indicating decreased function or greater pain, while mean SMFA scores were higher than published population norms indicating greater impairment and bother. The mean LEFS score was 40.78 ± 15.90 out of a maximum score of eighty. At the univariate level, the presence of complications was a significant predictor of both the SMFA bother (p=0.002) and dysfunction scores (p=0.015), while positive smoking status was a significant predictor of the bother score (p=0.002). Based on a multivariate linear regression model, the presence of complications (p=0.013) and positive smoking status (p=0.011) were both significant predictors of a higher SMFA bother score. In the multivariate model for SMFA dysfunction score, the presence of complications (p=0.014) and the presence of comorbidities (p=0.017) were significant predictors of a higher score.

Comparing SF-36 and SMFA scores with published population norms, supracondylar femur fractures were associated with residual impact. Based on our analysis, smoking, the presence of medical comorbidities at the time of fracture, and the occurrence of complications following fracture repair were the main predictors of poorer patient outcomes following supracondylar femur fracture.

We aimed to establish if radiological parameters, dual energy x-ray absorbtiometry (DEXA) and quantitative CT (qCT) could predict the risk of sustaining a femoral neck fracture following hip resurfacing.

Twenty-one unilateral fresh frozen femurs were used. Each femur had a plain AP radiograph, DEXA scan and quantitative CT scan. Femurs were then prepared for a Birmingham Hip Resurfacing femoral component with the stem shaft angle equal to the native neck shaft angle. The femoral component was then cemented onto the prepared femoral head. No notching of the femoral neck occurred in any specimens. A repeat radiograph was performed to confirm the stem shaft angle. The femurs were then potted in a position of single leg stance and tested in the axial direction to failure using an Instron mechanical tester. The load to failure was then analysed with the radiological, DEXA and qCT parameters using multiple regression.

The strongest correlation with the load to failure values was the total mineral content of the femoral neck at the head/neck junction using qCT r= 0.74 (p< 0.001). This improved to r=0.76 (p< 0.001) when neck width was included in the analysis. The total bone mineral density measurement from the DEXA scan showed a correlation with the load to failure of r=0.69 (p< 0.001). Radiological parameters only moderately correlated with the load to failure values; neck width (r=0.55), head diameter (r= 0.49) and femoral off-set (r=0.3).

This study suggests that a patient’s risk of femoral neck fracture following hip resurfacing is most strongly correlated with total mineral content at the head/neck junction and bone mineral density. This biomechanical data suggests that the risk of post-operative femoral neck fracture may be most accurately identified with a pre-operative quantitative CT scan through the head/neck junction combined with the femoral neck width.

To investigate differences between the Reamer Irrigator Aspirator and the AO reamer on fat embolism outcome using a porcine model.

All animal procedures were approved and performed in accordance with the Animal Care Committee at St. Michael’s hospital. Following anesthetic administration, the animals were stabilised for thirty minutes. One third of the pig’s blood volume was withdrawn to simulate hemorrhagic shock. Each animal was kept in a state of hypovolemia for an hour before transfusion and resuscitation. Once the animal was stabilised surgical exposure of the distal femur was completed. A 12 mm Reamer Irrigator Aspirator or AO reamer was used depending on which group the animal was assigned to. Blood work was obtained at: baseline, immediately after induction of hypovolemia, one hour post hypovolemia, post stabilization, one minute, five minutes, 1.5 hours and three hours after reaming. The results were analyzed for activation of the coagulation system, platelet and neutrophil activation, and cytokine elevation. ANOVA was the primary tool used to assess statistical significance.

There was no statistical difference between the two reamers with respect to PT, APTT, and fibrinogen. There was a statistical difference in D-dimer at 1.5 and three hours post-reaming, with the RIA showing a lower value. Neither reamer demonstrated any systemic platelet nor neutrophil activation. TNF-alpha spiked immediately post-reaming with the RIA group returning to baseline values and the AO group remaining elevated. There is a spike in IL-1B post reaming in the AO group, however this was not seen in the RIA group. No statistical difference was detected between the two reamers.

All markers for platelet and neutrophil activation and the coagulation cascade were measured at the systemic level. Although there is no statistical difference between the RIA and AO reamer, it is possible that activated cells were removed from the systemic circulation and sequestered as thrombi in the pulmonary microvasculature. This hypothesis may be supported by a drop in platelet count and an increase in D-dimer, with the AO reamer suggesting greater thrombi formation. The trends in IL-1B and TNF-alpha seem to suggest that the RIA abrogates the post-reaming proinflammatory state.

Purpose: To determine the differences in bone remodelling between a metaphyseal and a diaphyseal fixed stem in uncemented total hip arthroplasty.

Methods: Twenty-three patients undergoing uncemented total hip arthroplasty (28 hips) utilizing a metaphyseal fit stem were matched to 27 patients (32 hips) undergoing uncemented total hip arthroplasty utilizing a diaphyseal fit stem. Patients were matched for age, gender and follow-up. All patients were assessed by clinical and radiographic examination at 6 weeks, 3 months, 6 months and yearly thereafter. Radiographs were assessed for periprosthetic bone remodelling, canal fill, canal shape and bone quality using the cortical index and the Singh index. At latest follow-up all radiographs were assessed for frequency and time of appearance of spot welds, cortical hypertrophy and development of pedestal formation. All patients were assessed clinically utilizing the modified Harris hip score.

Results: At one year there was no difference in the clinical results between the two groups of patients utilizing the modified Harris hip score 90.6 + 1.5 in metaphyseal fit stems versus 91.7 + 1.7 for diaphyseal fit stems (p> 0.05). There was no statistical difference between the two groups in either femoral canal shape or bone quality–canal-to-calcar ratio 0.49 versus 0.45 (p> 0.05); cortical index 0.45 versus 0.44 (p> 0.05); Singh index 3.44 versus 3.70 (p> 0.05). In assessing canal fill proximal canal fill was statistically greater in metaphyseal fit stems and distal canal fill was significantly greater in diaphyseal fit stems (p< 0.01). There was a statistically significant increase in the frequency and timing of spot welds in metaphyseal stems at 3 months and 6 months (p< 0.05) but no difference in the frequency of spot welds at 1 year and 2 years. Cortical hypertrophy was significantly increased at 6 months, 1 year and 2 years in metaphyseal fit stems as compared to diaphyseal fit stems (p< 0.05). There was no difference in pedestal formation at 1 year or 2 years between the two stem groups (p> 0.05).

Conclusions: After one year the only significant difference between these two groups of patients is increased cortical hypertrophy in those patients undergoing metaphyseal versus diaphyseal stem insertion. Both stem designs demonstrated bone remodelling with no differences in spot welds or pedestal formation. At two years there was no functional difference between these two patient groups.

We aimed to identify whether patients in lower socioeconomic groups had worse function prior to total knee arthroplasty and to establish whether these patients had worse post-operative outcome following total knee arthroplasty. Data was obtained from the Kinemax outcome study, this was a prospective observational study of 974 patients undergoing primary total knee arthroplasty for osteoarthritis. The study was undertaken in thirteen centers, four in the United States, six in the United Kingdom, two in Australia and one in Canada. Pre-operative data was collected within six weeks of surgery and patients were followed for two years post-operatively. Pre-operative details of the patient’s demographics, socioeconomic status (education and income), height, weight and co-morbid conditions were obtained. The WOMAC and SF-36 scores were also obtained. Multivariate regression was utilised to analyse the association between socioeconomic status and the patient’s pre-operative scores and post-operative outcome. During the analysis, we were able to control for variables that have previously been shown to effect pre-operative scores and post-operative outcome. Patients with a lower income had a significantly worse pre-operative WOMAC pain (p=0.021) and function score (p=0.039) than those with higher incomes. However, income did not have a significant impact on outcome except for WOMAC Pain at 12-months (p=0.014). At all the other post-operative assessment times, there was no correlation between income and WOMAC Pain and WOMAC Function. Level of education did not correlate with pre-operative scores or with outcome at any time during follow-up. This study demonstrates that across all four countries, patients with lower incomes appear to have a greater need for total knee arthroplasty. However, level of income and educational status did not appear to effect the final outcome following total knee arthroplasty. Patients with lower incomes appear able to compensate for their worse pre-operative score and obtain similar outcomes post-operatively.

Alignment of the femoral component during hip resurfacing has been implicated in the early failure of this device. Techniques to facilitate a more accurate placement of the femoral component may help prevent these early failures. We aim to establish whether the use of imageless computer navigation can improve the accuracy in alignment of the femoral component during hip resurfacing.

6 pairs of cadaveric limbs were randomized to the use of computer navigation or standard instrumentation. All hips had radiographs taken prior to the procedure to facilitate accurate templating. All femoral components were planned to be implanted with a stem shaft angle of 135 degrees. The initial guide wire was placed using either the standard jig with a pin placed in the lateral cortex or with the use of an imageless computer navigation system. The femoral head was then prepared in the same fashion for both groups. Following the procedure radiographs were taken to assess the alignment of the femoral component.

The mean stem shaft angle in the computer navigation group was 133.3 degrees compared to 127.7 degrees in the standard instrumentation group (p=0.03). The standard instrumentation group had a range of error of 15 degrees with a standard deviation of 4.2 degrees. The computer navigated group had a range of error of only 8 degrees with a standard deviation of 2.9 degrees.

Our results demonstrated that the use of standard alignment instrumentation consistently placed the femoral component in a more varus position when compared to the computer navigation group. The computer navigation was also more consistent in its placement of the femoral component when compared to standard instrumentation. We suggest that imageless computer navigation appears to improve the accuracy of alignment of the femoral component during hip resurfacing.

Purpose: The purpose of this study was to evaluate total hip arthroplasty (THA) in the treatment of posttraumatic arthritis following acetabular fracture and to compare the long-term outcome of THA after previous open reduction and internal fixation (ORIF) or conservative treatment of the acetabular fracture.

Method: Thirty-four patients (thirty-six hips) underwent total hip arthroplasty for arthritis resulting from acetabular fractures. There were twenty-six males (27 hips) and eight females (9 hips). The mean age at the time of hip arthroplasty was 49 years (range, 25–78 years). The mean follow-up was eight years and nine months (range, 4–17 years). The mean interval from fracture to arthroplasty was 7.5 years (range, 5 months-29 years). Two patients died of unrelated causes and two patients were lost to follow up. Thirty patients (32 hips) were available for latest follow up. Twenty-one hips had been previously treated by open reduction internal fixation and 11 hips had conservative treatment.

Results: Sixteen patients achieved and maintained a good to excellent result over the course of the follow-up. There was no difference in improvement of mean Harris Hip Score between both groups (p> 0.05).

Ten out of 32 hips required revision; 9 acetabular components were revised because of aseptic loosening (3), osteolysis/excessive wear (4), instability (1) and infection (1) with a total revision rate of 28%. Eight patients needed acetabular revision alone, one femoral revision alone and one revision of both components. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (p> 0.05).

Conclusions: Those patients initially treated conservatively had similar long term results compared to those treated primarily by open reduction internal fixation. At long term follow-up the main problem identified was osteolysis and acetabular wear.

We aimed to establish if radiological parameters, dual energy x-ray absorbtiometry (DEXA) and quantitative CT (qCT) could predict the risk of sustaining a femoral neck fracture following hip resurfacing. 21 unilateral fresh frozen femurs were used. Each femur had a plain AP radiograph, DEXA scan and quantitative CT scan. Femurs were then prepared for a Birmingham Hip Resurfacing femoral component with the stem shaft angle equal to the native neck shaft angle. The femoral component was then cemented onto the prepared femoral head. No notching of the femoral neck occurred in any specimens. A repeat radiograph was performed to confirm the stem shaft angle. The femurs were then potted in a position of single leg stance and tested in the axial direction to failure using an Instron mechanical tester. The load to failure was then analysed with the radiological, DEXA and qCT parameters using multiple regression. The strongest correlation with the load to failure values was the total mineral content of the femoral neck at the head/neck junction using qCT r= 0.74 (p< 0.001). This improved to r=0.76 (p< 0.001) when neck width was included in the analysis. The total bone mineral density measurement from the DEXA scan showed a correlation with the load to failure of r=0.69 (p< 0.001). Radiological parameters only moderately correlated with the load to failure values; neck width (r=0.55), head diameter (r= 0.49) and femoral off-set (r=0.3). This study suggests that a patient’s risk of femoral neck fracture following hip resurfacing is most strongly correlated with total mineral content at the head/neck junction and bone mineral density. This biomechanical data suggests that the risk of post-operative femoral neck fracture may be most accurately identified with a pre-operative quantitative CT scan through the head/neck junction combined with the femoral neck width.

Introduction: We aimed to examine the effect of neck notching during hip resurfacing on the strength of the proximal femur.

Methods: Third generation composite femurs that have been shown to replicate the biomechanical properties of human bone were utilised. Imageless computer navigation was used to position the initial guide wire during head preparation. Six specimens were prepared without a superior notch being made in the neck of the femur, six were prepared in an inferiorly translated position to cause a 2mm notch in the superior femoral neck and six were prepared with a 5mm notch. All specimens had radiographs taken to ensure that the stem shaft angle was kept constant. The specimens were then loaded to failure in the axial direction with an Instron mechanical tester.

A three dimensional femoral finite element model was constructed and molded with a femoral component constructed from the dimensions of a Birmingham Hip Resurfacing. The model was created with a superior femoral neck notch of increasing depths.

Results: The 2mm notched group (mean load to failure 4034N) were significantly weaker than the un-notched group (mean load to failure 5302N) when tested to failure (p=0.017). The 5mm notched group (mean load to failure 3121N) were also significantly weaker than the un-notched group (p=0.0003) and the 2mm notched group (p=0.046). All fractures initiated at the superior aspect of the neck, at the component bone interface. The finite element model revealed increasing Von Mises stresses with increasing notch depth.

Discussion: A superior notch of 2mm in the femoral neck weakens the proximal femur by 24% and a 5mm notch weakens it by 41%. This study provides biomechanical evidence that notching of the femoral neck may lead to an increased risk of femoral neck fracture following hip resurfacing due to increasing stresses in the region of the notch.

Introduction: It has been suggested that femoral component alignment in the coronal plane affects the risk of sustaining femoral neck fracture following hip resurfacing. Previous literature suggests that increasing the stem shaft angle to an extreme valgus position produces the most favourable biomechanical properties following femoral component insertion. We examined the effects of femoral component alignment during hip resurfacing on proximal femur strength.

Methods: 3^rd generation composite femurs shown to replicate biomechanical properties of human bone were used. The bones were secured in a position of single leg stance and tested with an Instron mechanical tester. Imageless computer navigation was used to position the guide wire during femoral head preparation. Specimens were placed in 115, 125 and 135 degrees of stem shaft angulation. No notching was made in the femoral neck during head preparation. The femoral components were cemented in place. Radiographs were taken ensuring that stem shaft angles were correct. Specimens were loaded to failure in the axial direction.

Results: A component position of 115 degrees compared to 125 degrees reduced load to failure from 5475N to 3198N (p=0.009). A position of 135 degrees (5713N) compared to 125 degrees (5475N) did not significantly alter the load to failure (p=0.347). Component positioning at a stem shaft angle below 125 degrees resulted in a significant reduction in strength of the proximal femur. Placement of the component at 115 degrees reduced the load to failure by 42%.

Discussion: Our findings suggest that a varus orientation may be at risk for causing femoral neck fracture. The advantages of increasing valgus angle beyond 125 degrees may not provide as much reduction in the incidence of femoral neck fracture as previously suggested, particularly when considering the inherent risk of femoral neck notching in these positions.

Introduction: When performing a hip resurfacing procedure through the postero-lateral approach, concern has been expressed as to the proximity of the femoral neurovascular bundle during the anterior capsulotomy. We aimed to identify the proximity of the femoral nerve, artery and vein during an anterior capsulotomy.

Methods: 5 fresh frozen cadaveric limbs were used. A standard postero-lateral approach was performed. An anterior incision was then made to identify the femoral neurovascular bundle. Measurements were taken prior to hip dislocation. The femoral head was dislocated, capsulotomy scissors were inserted though the posterior incision and positioned to cut the superior and then inferior aspects of the anterior capsule. The distance from the scissors to each of the neurovascular structures were recorded. Measurements were made with the hip in flexion and extension.

Results: Prior to dislocation the mean distance from the capsule was 25mm for the femoral nerve, 21mm for the artery and 21mm for the vein. Following dislocation, with the hip in extension the distance during cutting of the antero-superior capsule to the nerve, artery and vein was 31mm. With the hip in a flexed position, the distance from all three neurovascular structures increased by a mean of 5mm. When the scissors were positioned to cut the antero-inferior capsule in extension, the mean distances to the nerve, artery and vein were 31mm, 28mm and 28mm. When the hip was flexed, the distance to the nerve decreased by 2mm.

Discussion: Our study suggests that the neurovascular structures are relatively well protected during an anterior capsulotomy performed during hip resurfacing. The procedure may be safer if the capsulotomy is performed with the hip dislocated and the hip in a flexed position while cutting the antero-superior aspect and in an extended position while cutting the antero-inferior aspect.

Introduction: Notching of the femoral neck during preparation of the femur during hip resurfacing has been associated with an increased risk of femoral neck fracture. We aimed to evaluate this with the use of a finite element model.

Methods: A three dimensional femoral model was used and molded with a femoral component constructed from the dimensions of a Birmingham Hip Resurfacing. Multiple constructs were made with the component inferiorly translated in order to cause a notch in the superior femoral neck. The component angulation was kept constant. Once constructed the model was imported into the Ansys finite element model software for analysis. Elements within the femoral model were assigned different material properties depending on cortical and cancellous bone distributions. Von Misses stresses were evaluated near the notches and compared in each of the cases.

Results: In the un-notched case the maximum Von Mises stress was only 40MPa. However, with the formation of a 1mm notch the stress rose to 144MPa and in the 4 mm notch the stress increased to 423MPa. These values demonstrated that a 1mm notch increased the maximum stress by 361% while a 4mm notch increased the maximum stress by 1061%.

Discussion: This study demonstrated that causing a notch in the superior femoral neck dramatically increases the stress within the femoral neck. This may result in the weakening of the femoral neck and potentially predispose it to subsequent femoral neck fracture. The data suggests that even a small notch of 1mm may be detrimental in weakening the femoral neck by dramatically increasing the stress in the superior neck. This study suggests that any femoral neck notching should be avoided during hip resurfacing.

Introduction: It has been suggested that notching of the femoral neck during hip resurfacing weakens the proximal femur and predisposes to femoral neck fracture. We aimed to examine the effect of neck notching during hip resurfacing on the strength of the proximal femur.

Methods: 3^rd generation composite femurs that have been shown to replicate the biomechanical properties of human bone were utilised. The bone was secured in a position of single leg stance and tested with an Instron mechanical tester. Imageless computer navigation was used to position the initial guide wire during head preparation. Six specimens were prepared without a superior notch being made in the neck of the femur, six were prepared in an inferiorly translated position to cause a 2mm notch in the superior femoral neck and six were prepared with a 5mm notch. The femoral component was then cemented in place. All specimens had radiographs taken to ensure that the stem shaft angle was kept constant. The specimens were then loaded to failure in the axial direction.

Results: The 2mm notched group (mean load to failure 4034N) were significantly weaker than the un-notched group (mean load to failure 5302N) when tested to failure (p=0.017). The 5mm notched group (mean load to failure 3121N) were also significantly weaker than the un-notched group (p=0.0003) and the 2mm notched group (p=0.046). All fractures initiated at the superior aspect of the neck, at the component bone interface. All components were positioned in the same coronal alignment +/−2 degrees.

Discussion: A superior notch of 2mm in the femoral neck weakens the proximal femur by 24% and a 5mm notch weakens it by 41%. This study provides biomechanical evidence that notching of the femoral neck may lead to an increased risk of femoral neck fracture following hip resurfacing.

This study was undertaken to assess the contribution of pulmonary fat embolism to systemic platelet activation in a rabbit model of fat embolism. Fifteen NZW rabbits were randomly assigned into one of two groups: fat embolism and control. Fat embolism was induced via intramedullary canal pressurization with a 1–1.5 ml bone cement injection. Only the animals that underwent fat embolism displayed consistent platelet activation, as demonstrated by platelet degranulation and procoagulatory surface expression. These findings suggest that fat embolism plays a role in platelet activation and in the overall activation of hemostasis following trauma.

The objective of this study was to use a recently developed rabbit model of fat embolism to assess the systemic hemostatic response to pulmonary fat embolism.

Our findings demonstrate platelet activation following forced liberation of bone marrow contents into the circulation only in the FE group, as demonstrated by CD62P elevation (a marker of platelet degranulation) and annexin V elevation (a marker of procoagulatory surface expression). Platelet activation also coincided with significantly lower platelet counts in the FE group at two and four hours post embolism, suggesting platelet aggregation.

These findings suggest that fat embolism plays a role in platelet activation and in the overall activation of hemostasis following trauma.

Platelet count decreased significantly at two and four hours post knee manipulation only in the FE group. Annexin V expression increased significantly in the FE group at two and four hours post knee manipulation. Lastly, CD62P expression only increased significantly in the FE group at two hours post knee manipulation

Fifteen New Zealand White male rabbits were randomly assigned into one of two groups: control and fat embolism (FE). In FE group (n=8), the intramedullary cavity was drilled, reamed and pressurized with a 1–1.5 ml bone cement injection. In the control group (n=7), a sham knee incision was made, exposing both femoral condyles, but was immediately closed without further manipulations. All animals were mechanically ventilated for an additional monitoring period of four hours post-surgical closure. For flow cytometric evaluation of platelet activation, blood samples were stained with fluorescence-conjugated antibodies against CD41 (FITC), CD62P (P-selectin) and annexin V (FITC). Platelet events were identified by their characteristic CD41 staining and size and were analyzed using a flow cytometer. All animals were mechanically ventilated for four hours post surgical closure.

The implications of platelet activation following fat embolism are numerous, ranging from adherence and aggregation, to secretion of key components of both the coagulation and inflammatory cascades.

Bone transport/limb lengthening with circular external fixation has been associated with a prolonged period of time in the frame and a significant major complication rate following frame removal. We examined the results of bone transport in fifty-one limbs using the “monorail” technique and found a dramatically improved lengthening index (24.5 days/cm. – time in frame /cm. of length gained) and an absence of refracture or angulatory deformity following fixator removal. This technique is our treatment of choice for limb lengthening/bone transport.

We sought to determine patient oriented outcome and complication rates following b one transport using an external fixator placed over an intramedullary nail (the “monorail” technique).

Bone transport using the monorail technique is associated with a dramatically improved lengthening index and a lower major complication rate than traditional ring fixator methods. Patient satisfaction with the procedure was high.

Our study confirms the significant advantages of the monorail technique for bone transport/limb lengthening. The time in the fixator is dramatically reduced, and complications associated with earlier techniques such as angulatory deformity or refracture were not seen.

We identified forty-nine patients (fifty-one limbs) who had undergone bone transport using the monorail technique (external fixator placed over an intramedullary nail). There were thirty-five men and fourteen women with a mean age of thirty-five years (range 17–50). Pre-operative diagnoses included post traumatic length discrepancy/bone defect (forty-one), congenital short stature (six) and other (four). All patients had a unilateral fixator placed over an implanted intramedullary nail. Once length correction was achieved, the fixator was removed and the nail “locked”. The mean amount of lengthening was 5.5 cm. (range 2 – 18 cm.). The lengthening index was 24.5 days /cm. (duration of external fixation/cm. bone length gained), with a range from ten to fifty days /cm. There were nineteen complications (thirty-seven percent): nine premature consolidations, four infected pin sites, two hardware failures, two osteomyelitis, one DVT, one nonunion. There were no refractures, angulatory deformities or cases of intramedullary sepsis.

Clinicians ask patients “How are you now?” to ascertain treatment outcomes and to set a plan for subsequent care. However, sometimes patient views do not agree with those of the clinicians. This study compared patient and clinician views of outcome one to two years after an operatively managed extremity fracture and described any discordance. There were significant differences between groups, especially in areas such as pain and disruption of their personal and work lives. A discordance was observed between patient and physician views of recovery after fracture, likely associated with disruptions to personal life, unaccounted for in a clinician’s view of outcome.

Clinicians ask patients “How are you now?” to ascertain treatment outcomes and to set a plan for subsequent care. However, sometimes patient views differ from those of clinicians’.

The purpose of this study is to compare patient and clinician views of outcome one to two years after an extremity fracture and to describe any discordance.

Cross-sectional survey of patients one to two years after an operatively managed upper or lower extremity fracture. Patients were recruited from two tertiary care centres and completed a mailback questionnaire that included measures of health (DASH, SMFA), self-rated recovery, burden of illness (Illness Intrusiveness, Loss of self), symptoms, and work status. These were linked with clinical records of radiologic and clinical recovery.

Two hundred and fifty-five patients returned usable questionnaires. Mean age was forty-two years and 42% were female. Sixty-seven patients said that they were completely better (CB), one hundred and thirty-four almost better (AB) and fifty-four not completely better (NCB). Significant differences were found between groups. In four variables, NCB was distinct from AB/CB, while in all other variables, such as pain, disability and disruption of their personal and work lives, all three groups were unique (Duncan’s post hoc). However, of the patients who said they were not better, the radiologist and clinician reports stated that thirty (68%) and twenty-eight (64%) were healed, respectively.

A discordance was observed between patient and physician views of recovery after fracture. It appeared associated with disruptions to personal life that may not be accounted for in a clinician’s view of outcome.

Funding: Canadian Institutes of Health Research (CIHR)

Purpose: The purpose of this study was to evaluate total hip arthroplasty in the treatment of post-traumatic arthritis following acetabular fracture and to compare the long-term outcome of THA after previous open reduction and internal fixation or conservative treatment of the acetabular fracture.

Methods: Thirty-four patients (thirty-six hips) underwent total hip arthroplasty for arthritis resulting from an acetabular fracture. The mean age at the time of hip arthroplasty was 49 years. The mean follow-up was eight years and nine months (range, 4–17 years). The mean interval from fracture to arthroplasty was 7.5 years (range, 5 months-29 years). Twenty-three hips had been previously treated by open reduction and internal fixation and 12 hips had a conservatively treated fracture. An uncemented arthroplasty was performed in 31 hips, cemented arthroplasty in 2 patients and a hybrid replacement in 2 patients.

Results: Only 16 patients achieved and maintained a good to excellent result over the course of the follow-up. The mean Harris hip score improved from 44.5 points preoperatively to 72.76 points for operatively treated fractures (23 patients). The mean Harris hip score improved from 44.2 points preoperatively to 78.7 points for conservatively treated fractures (12 patients) (p> 0.05). Ten out of 35 hips required revision; 9 were revised because of aseptic loosening and one for infection with a total revision rate of 29%. Femoral bone quality was significant in predicting revision. No femoral radiographic loosening was found at latest follow-up. On the acetabular side, the rate of radiographic loosening was higher. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (ORIF vs conservative treatment of acetabular fracture) (p> 0.05).

Conclusions: Outcome following total hip arthroplasty in the treatment of post-traumatic arthritis following acetabular fracture is less favourable than following primary osteoarthritis. Those patients initially treated conservatively had similar long term results compared to those treated primarily by open reduction and internal fixation. At long term follow-up, the main problem identified was osteolysis and acetabular wear.

When deciding on treatment for displaced mid-shaft clavicle fractures, patients often inquire if repair of (potential) nonunion results in outcome similar to acute fixation. We used objective muscle strength testing and patient-oriented outcome measures to examine this question. Late reconstruction of nonunion following displaced mid-shaft fractures of the clavicle results in restoration of objective muscle strength similar to that seen with immediate fixation. However, there was a significant loss in muscle endurance as well as a trend towards a decrease in outcome scores (DASH, Constant) following late reconstruction. This information is useful in surgical decision making and in counseling patients.

Using objectively measured strength and patient-oriented health-status instruments, we sought to determine if delay in repair of displaced, mid-shaft clavicle fractures negatively affected shoulder strength or outcome.

Late reconstruction of clavicle nonunion results in restoration of objective muscle strength similar to that seen with immediate fracture fixation, but there was a significant loss in muscle endurance as well as a trend towards a decrease in outcome scores (DASH, Constant).

All patients had sustained completely displaced, closed, isolated mid-shaft clavicle fractures. Fifteen patients had immediate plate fixation (mean 0.6 months post-fracture) and fifteen had plate fixation for non-union (mean fifty-eight months post-fracture). Objective muscle strength testing on the BTE was done a mean of twenty-nine months post-fixation (normal contralateral limb as control). There were no significant differences between acute fixation and delayed reconstruction groups with regards to strength of shoulder flexion (acute = 92.4%, delayed = 89.4%, p=0.56), shoulder abduction (acute = 98.8%, delayed = 96.7, p=0.75), external rotation (acute = 98.4%, delayed = 91.9%, p=0.29), or internal rotation (acute = 96.3%, delayed = 97.4%, p=0.87). However, there was a trend for improved Constant scores (acute = 94.5, delayed = 90, p=0.09) and the DASH scores (acute = 3.4, delayed = 9.0, p=0.09) in the acute fixation group. We found a significant decrease in muscle endurance with regards to shoulder flexion (acute = 107.0%, delayed = 71.1%, p=0.007) and a trend towards weaker shoulder abduction (acute = 103.1%, delayed = 88.7 %).

Funding: Mr. Potter was supported by a St. Michael’s Hospital Summer Student Scholarship

Purpose: In uncemented total hip arthroplasty, stem design is one of the important factors influencing bone remodeling. The purpose of this study was to determine the differences in bone remodeling between metaphyseal and diaphyseal fit stems.

Methods: Twenty-three patients undergoing total hip arthroplasty (28 hips) with metaphyseal fit stems were matched to 27 patients (32 hips) undergoing uncemented total hip arthroplasty with diaphyseal fit stems. Preoperative radiographs were assessed for canal fill, canal shape, and bone quality. Postoperative radiographs were assessed for frequency and time of appearance of peri-prosthetic bone remodeling including spot welds, cortical hypertrophy and pedestal formation. All patients were examined by a modified Harris Hip Score.

Results: The proximal canal shape and bone quality were similar in both groups. There was no difference in the frequency of spot welds at 1 year and 2 years. Spot welds were mainly located in Gruen zone 1. Cortical hypertrophy was greater (p < 0.05) at 6 months, 1 year and 2 years with the metaphyseal fit stem. Cortical hypertrophy was found only in Gruen zones 3 and 5. Halo pedestal formation was greater (p < 0.05) at 6 months with the metaphyseal fit stem but not at 1 year and 2 years. Calcar rounding was observed in 25 hips (90.0%) with metaphyseal fit stems and twenty hips (62.5%) with diaphyseal fit stems. At the last follow-up, average HHS was similar (90.6 +/− 1.5 / 91.7 +/− 1.7; metaphyseal / diaphyseal fit stems). No patient developed aseptic loosening.

Conclusions: This is the first study to determine differences in bone remodeling between a metaphyseal and a diaphyseal fixed stem in uncemented THA. After one year, the only significant difference between these two groups was cortical hypertrophy, which was greater in patients undergoing metaphyseal fit stem insertion. Both stem designs demonstrated bone remodeling with no differences in spot welds or pedestal formation. At two years, there was no functional difference between these two patient groups. To further elucidate the relation between radiographic and clinical results, longer term follow-up is required.

We report preliminary results from the first, multicenter prospective study designed to define the incidence of symptomatic (Venous Thromboembolism) VTE in patients with isolated leg fractures distal to the knee. Eight hundred and twenty-six enrolled patients have completed three months of follow up. By three months, only seven patients had sustained a symptomatic VTE with no fatal PE. Symptomatic and fatal VTE were infrequent complications after isolated leg fractures distal to the knee without thromboprophylaxis. Routine thromboprophylaxis may not be warranted in isolated leg fractures distal to the knee.

To report results from the first, multicenter prospective study designed to define the incidence of symptomatic Venous Thromboembolism (VTE) in patients with isolated leg fractures distal to the knee.

Symptomatic and fatal VTE are infrequent complications after isolated leg fractures distal to the knee without thromboprophylaxis.

Routine thromboprophylaxis may not be warranted in isolated leg fractures distal to the knee.

From August 2002 to April 2004, one thousand eight hundred and eight consecutive patients with isolated leg fractures distal to the knee were screened for entry at five hospitals in Ontario. Patients with major trauma, active cancer and previous VTE were excluded. Thromboprophylaxis was not allowed. Patients were followed prospectively for three months, with telephone calls at fourteen days, six weeks and three months. Suspected DVT and PE were investigated in a standardized manner.

Eight hundred and twenty-six enrolled patients have completed three months of follow up. The mean age was forty-five years (range sixteen to ninety-three) and 59.5% of this cohort was female. 99% of these fractures were unilateral and 97% were closed. Fractures included: fibula (38%), metatarsal (29%), phalanges (13%), calcaneus, talus or tarsal (10%), tibia (10%) and patella (7%). Only 11% of fractures were surgically treated. 88% of fractures received a cast or splint for a mean duration of 41+/− 20 days. Complete follow-up was available for 97.5% of this cohort. By three months only seven patients had sustained a symptomatic VTE (2 proximal DVT, 3 calf DVT, 2 PE) with no fatal PE-an incidence of 0.9% (95% CI 0.3 to 1.8%).

Funding: This study was funded by a research grant from Pharmacia