Aims

The aim of this study was to report the three-year follow-up for a series of 400 patients with a displaced intracapsular fracture of the hip, who were randomized to be treated with either a cemented polished tapered hemiarthroplasty or an uncemented hydroxyapatite-coated hemiarthroplasty.

Abstract

Introduction and Objective

The effectiveness of anti-embolic graduated compression stockings (GCSs) has recently been questioned. The aim of this study is to systematically review all the relevant randomised controlled trials published to date.

We performed a systematic review and meta-analysis of modern total ankle replacements (TARs) to determine the survivorship, outcome, complications, radiological findings and range of movement, in patients with end-stage osteoarthritis (OA) of the ankle who undergo this procedure. We used the methodology of the Cochrane Collaboration, which uses risk of bias profiling to assess the quality of papers in favour of a domain-based approach. Continuous outcome scores were pooled across studies using the generic inverse variance method and the random-effects model was used to incorporate clinical and methodological heterogeneity. We included 58 papers (7942 TARs) with an interobserver reliability (Kappa) for selection, performance, attrition, detection and reporting bias of between 0.83 and 0.98. The overall survivorship was 89% at ten years with an annual failure rate of 1.2% (95% confidence interval (CI) 0.7 to 1.6). The mean American Orthopaedic Foot and Ankle Society score changed from 40 (95% CI 36 to 43) pre-operatively to 80 (95% CI 76 to 84) at a mean follow-up of 8.2 years (7 to 10) (p < 0.01). Radiolucencies were identified in up to 23% of TARs after a mean of 4.4 years (2.3 to 9.6). The mean total range of movement improved from 23° (95% CI 19 to 26) to 34° (95% CI 26 to 41) (p = 0.01).

Our study demonstrates that TAR has a positive impact on patients’ lives, with benefits lasting ten years, as judged by improvement in pain and function, as well as improved gait and increased range of movement. However, the quality of evidence is weak and fraught with biases and high quality randomised controlled trials are required to compare TAR with other forms of treatment such as fusion.

Cite this article: Bone Joint J 2013;95-B:1500–7.

Introduction

Surgeons, commissioners and patients are increasingly seeking more in depth details on outcomes of total ankle replacement (TAR). We set out to perform a detailed and up to date meta-analysis of the outcomes of TAR, with a focus on PROMS.

We undertook a prospective randomised controlled trial involving 400 patients with a displaced intracapsular fracture of the hip to determine whether there was any difference in outcome between treatment with a cemented Thompson hemiarthroplasty and an uncemented Austin-Moore prosthesis. The surviving patients were followed up for between two and five years by a nurse blinded to the type of prosthesis used.

The mean age of the patients was 83 years (61 to 104) and 308 (77%) were women. The degree of residual pain was less in those treated with a cemented prosthesis (p < 0.0001) three months after surgery. Regaining mobility was better in those treated with a cemented implant (p = 0.005) at six months after operation. No statistically significant difference was found between the two groups with regard to mortality, implant-related complications, re-operations or post-operative medical complications.

The use of a cemented Thompson hemiarthroplasty resulted in less pain and less deterioration in mobility than an uncemented Austin-Moore prosthesis with no increase in complications.

1133 patients with an intracapsular fractures of femoral neck treated by internal fixation were prospectively studied. All surviving patients were followed up for a minimum of one year from injury. The overall incidence of non-union was 229(20.2%) and the incidence of avascular necrosis was 61(5.4%). Fracture non-union was less common for undisplaced fracture in comparison to displaced fractures [48 out of 565(8.5%) versus 181 out of 568(31.9%)] and in males than females [45 out of 271(16.6%) versus 184 out of 862(21.3%)]. The incidence of non-union progressively increased with age from one out of 17(5.9%) in those aged below 40 years to 84 out of 337(24.9%) in those in their seventies. For those in their eighties the incidence of non-union began to fall, but if those patients who died within one year from injury were excluded, then the incidence was found to continue to increase. For avascular necrosis there was a falling incidence with age from 9 out of 68(13.2%) in those aged less than 50 years to 10 out of 388(2.6%) in those aged over 80 years.

The information from this large series of patients treated by contemporary methods enables to surgeon to use the three factors of age, sex and present of fracture displacement to predict the risk of non-union or avascular necrosis occurring.

Introduction and aim There are different methods of internal fixation of intracapsular fractures of the hip of which three AO screws is one of the more popular. There have been no evidence-based publications describing the optimal position for screws. The aim was to establish the relationship between screw position and angle, and subsequent failure of union.

Method Using computer software we studied the position of AO screws in 395 consecutive patients inserted between 1989 and 2003. Follow-up was prospective and for a minimum of 100 days. The diagnosis of non-union was made clinically and confirmed radiographically.

Results The mean age of our population was 73.9 years (range 22–96). Eighty-six (21.8%) were male. Three hundred and twenty seven (82.8%) came from their own home. The mean time between fall and surgery was 37.0 hours and between admission and surgery 20.9 hours. The mean length of radiographic follow-up for those fractures that did not develop non-union was 454 days (range 94–1898). Of the 395 patients 242 (61%) fractures united and 153 (39%) fractures suffered non-union.

Radiographic analysis suggests that the position of the screws on the AP view (superior, middle, inferior or spread) did not alter the outcome significantly. However three factors were related to lower risk of non-union on the lateral view: the closer the middle screw to the center of the head (p< 0.04), the more anterior the anterior screw (p< 0.008), and the greater the ‘spread’ between the anterior and posterior screws (p< 0.005).

Conclusions We conclude that to reduce the risk of non-union with screw fixation of intracapsular fractures of the hip, in the lateral view the middle screw must be positioned as close to the centre of the femoral head as possible, and the anterior and posterior screws achieve maximal spread.

Aim: Compressive forces on the medial femoral cortex and tensile forces at the lateral femoral cortex along with cortical comminution lead to a high risk of failure of surgical fixation of subtrochanteric fractures. The purpose of the study was to correlate the incidence of fracture healing complications to the surgical stabilisation method used.

Methods: A comprehensive search of various data sources extending from 1966 to October 2003 was conducted to identify appropriate studies using specific search terms. We also scanned the reference lists of eligible studies for potentially relevant reports. Articles of all languages were considered. Studies with a follow-up of less than six months, pathological fractures, fractures treated non-operatively and studies reporting on less than ten fractures were excluded. Abstracts were also excluded. Each eligible study was independently reviewed by authors for methodological quality. A methodological scoring system adapted from that of Detsky was used. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed.

Results: 39 studies including 1835 fractures were analysed. For extramedullary devices, the incidence of non-union (35/673 – 5.2%), delayed union (11/221 – 4.7%), implant breakage ( 24/444 – 5.1%) and deep infection (14/459 – 3.0%) was statistically significantly higher than non-union (14/506 – 2.7%), delayed union (5/529 – 0.94%), implant breakage (12/628 –1.9%) and deep infection (9/764 – 1.2%) for intramedullary devices. Mortality and superficial infection were higher for extramedullary than intramedullary devices. However, this was not statistically significant. Malunion, shortening and implant cut out were higher for intramedullary than extramedullary devices. This was not statistically significant.

Conclusion: The incidence of fracture healing complications appear to be significantly less with intramedullary than extramedullary devices. Based on this study, we advocate the use of intramedullary surgical fixation devices for subtrochanteric fractures.

Aim: The purpose of this study was to assess the various subtrochanteric fracture classification systems particularly in relation to their predictive value for choice of treatment and outcome.

Methods: A comprehensive search of various data sources extending from 1966 to October 2003 was conducted to identify appropriate studies using specific search terms. Articles of all languages were considered. From these articles and those referenced within them, the use of, and any description of fracture classifications were recorded. Abstracts and studies reporting on less than ten fractures were excluded. A methodological scoring system adapted from that of Detsky was used to assess the quality of studies. For each classification system, features such as proximal and distal margin of subtrochanteric fractures, number of subdivisions, advice for fractures which cross the described anatomical boundaries, number of publications using that classification system, published articles showing value in predicting outcome and published articles showing inter-observer variation were analysed.

Results: 110 studies involving 2725 fractures were identified. 16 different classification methods were analysed. The actual length of femur defined as the subtrochanteric zone varied from 3 cms to12 cms. There was no agreement between the different classifications regarding the proximal and distal borders, or for classifying fractures that traverse anatomical boundaries. None of the classifications systems was shown to be of value in determining treatment or for predicting outcome.

Conclusion: There is a need for a universally accepted definition for subtrochanteric fractures and sub-classifying such fractures is questionable. Indicators to a simple yet valid classification system which takes into account the variations of this fracture and which would assist in determination of treatment and prediction of outcome are proposed.

Previous studies on the timing of surgery for fracture of the hip provide conflicting evidence as to the effect of prolonged delay before operation. We have prospectively reviewed 3628 such fractures in patients older than 60 years of age. Those for whom the delay was for medical reasons were excluded. Patients were followed up for one year or until death. Operation was undertaken within 48 hours in 95.2% and after this in 4.8%. A significant increase in length of stay was found in patients operated on after 48 hours when compared with those in the earlier group (21.6 vs 32.5 days). No increase in hospital stay was found for lesser delays.

We have studied the placement of three screws within the femoral head and the degree of angulation of the screws in 395 patients with displaced intracapsular fracture of the hip to see if either was related to the risk of failure of the fracture to unite. No relationship between nonunion of the fracture was found regarding the position of the screws on the anteroposterior radiograph. However, we found that a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.