Objectives. The osteoprotegerin (OPG) and receptor activator of nuclear factor kappa-B ligand (RANKL) balance is of the utmost importance in fracture healing. The aim of this study was therefore to investigate the impact of nonosteogenic factors on OPG and RANKL levels. Methods. Serum obtained from 51 patients with long
We report the outcome of 19 children aged 5.2 to 13.2 years with 20 fractures of the femoral shaft requiring surgery, who were randomly assigned to have external fixation (EF) or flexible intramedullary nailing (FIN) (10 fractures each). The duration of the operation averaged 56 minutes for the EF group with 1.4 minutes of fluoroscopy, compared with 74 minutes and 2.6 minutes, respectively, for the FIN group. The early postoperative course was similar, but the EF group showed much more callus formation. The time to full weight-bearing, full range of movement and return to school were all shorter in the FIN group. The FIN complications included one transitory foot drop and two cases of bursitis at an insertion site. In the EF group there was one refracture, one rotatory malunion requiring remanipulation and two pin-track infections. At an average follow-up of 14 months two patients in the EF group had mild pain, four had quadriceps wasting, one had leg-length discrepancy of over 1 cm, four had malalignment of over 5°, and one had limited hip rotation. In the FIN group, one patient had mild pain and one had quadriceps wasting; there were no length discrepancies, malalignment or limitation of movement. Parents of the FIN group were more satisfied. We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft which require surgery, and reserve external fixation for open or severely comminuted fractures.
We have studied prospectively the effect of indomethacin on the development of heterotopic ossification (HO) after the internal fixation of acetabular fractures. After operation 107 patients randomly received either a six-week course of indomethacin or no treatment against HO. Plain radiographs of 101 patients at a mean of 7.9 months after surgery showed HO in 47.4% of the 57 patients who received indomethacin and in 56.8% of the 44 who did not. This difference was not statistically significant. Heterotopic ossification of Brooker class II or more was seen in four patients (7%) with prophylaxis and in one without (p = 0.51). Measurements of the volume of HO on 3-D CT reconstructions showed a median value of 1.5 cm3 in patients with indomethacin and 4.0 cm3 in those without (p = 0.28). When only the 57 patients in whom the operation was carried out through either a Kocher-Langenbeck or an extended iliofemoral approach were included the indomethacin group showed a median volume of 1.7 cm3 compared with 3.6 cm3. On plain radiographs Brooker class II or above was seen in 9.4% of the patients receiving indomethacin and in 4.8% of those who did not. Indomethacin was therefore not effective in preventing ectopic bone formation after surgery for acetabular fractures. There was a significant association of male gender with volume of HO using a non-parametric analysis of variance.
We compared the results of the surgical treatment of trochanteric hip fractures before and after surgeons had been introduced to the tip-apex distance (TAD) as a method of evaluating screw position. There were 198 fractures evaluated retrospectively and 118 after instruction. The TAD is the sum of the distance from the tip of the screw to the apex of the femoral head on antero-posterior and lateral views. This decreased from a mean of 25 mm in the control group to 20 mm in the study group (p = 0.0001). The number of mechanical failures by cut-out of the screw from the head decreased from 16 (8%) in the control group at a mean of 13 months to none in the study group at a mean of eight months (p = 0.0015). There were significantly fewer poor reductions in the study group. Our study confirms the importance of good surgical technique in the treatment of trochanteric fractures and supports the concept of the TAD as a clinically useful way of describing the position of the screw.
We evaluated 242 consecutive fractures of the clavicle in adults which had been treated conservatively. Of these, 66 (27%) were originally in the middle third of the clavicle and had been completely displaced. We reviewed 52 of these patients at a mean of 38 months after injury. Eight of the 52 fractures (15%) had developed nonunion, and 16 patients (31%) reported unsatisfactory results. Thirteen patients had mild to moderate residual pain and 15 had some evidence of brachial plexus irritation. Of the 28 who had cosmetic complaints, only 11 considered accepting corrective surgery. No patient had significant impairment of range of movement or shoulder strength as a result of the injury. We found that We now recommend open reduction and internal fixation of severely displaced fractures of the middle third of the clavicle in adult patients.
We reviewed 57 adult patients at an average of 37 months after early internal fixation for displaced fractures of the distal humerus. Two-thirds had intercondylar (Muller type C) fractures, and one-third had articular comminution (type C3). A chevron olecranon osteotomy was used, with early active movement after fixation. Results were good or excellent in 76% with an average range of movement of 115 degrees. Early stable fixation by an experienced surgeon is recommended for these fractures.
1. A method of treatment of displaced supracondylar fractures of the humerus in children by manipulative reduction and fixation in plaster in full extension of the elbow and supination of the forearm is described. 2. The method is easy, safe and requires a short period of hospitalisation. The carrying angle at the elbow can only be recorded, controlled and maintained when the elbow is extended and the forearm is fully supinated. Thus cubitus varus can be avoided. 3. The results of treatment in seventy-two displaced fractures treated by this method are reported. 4. Treatment by other methods is reviewed.
Surgical decompression of the spinal canal is presently accepted worldwide as the method of treatment for thoracolumbar burst fractures with neurological deficit in the belief that neurological recovery may be produced or enhanced. Our clinical and laboratory experience, however, indicates that the paralysis occurs at the moment of injury and is not related to the position of the fragments of the fracture on subsequent imaging. Since the preoperative geometry of the fracture may be of no relevance, our hypothesis, backed by more than two decades of operative experience, is that alteration of the canal by ‘surgical clearance’ does not affect the neurological outcome. We have reviewed the existing world literature in an attempt to find evidence-based justification for the variety of surgical procedures used in the management of these fractures. We retrieved 275 publications on the management of burst fractures of which 60 met minimal inclusion criteria and were analysed more closely. Only three papers were prospective studies; the remainder were retrospective descriptive analyses. None of the 60 articles included control groups. The design of nine studies was sufficiently similar to allow pooling of their results, which failed to establish a significant advantage of surgical over non-surgical treatment as regards neurological improvement. Significant complications were reported in 75% of papers, including neurological deterioration. Surgical treatment for burst fracture in the belief that neurological improvement can be achieved is not justified, although surgery may still occasionally be indicated for structural reasons. This information should not be withheld from the patients.
Twenty young men with displaced fractures of one or more long bones in the lower limb, but with no evidence of cranial, thoracic or abdominal injury, were studied prospectively. Although all the patients became hypoxaemic, the six who developed signs of respiratory distress (Group 1) were found to have a significantly lower arterial oxygen tension and a significantly higher rate of urinary urea excretion than the remaining 14 patients whose pulmonary function appeared to be clinically normal (Group 2). Circulating fat macroglobules were identified in three cases, only one of whom was in Group 1, and hence the tests for fat embolism were not of prognostic value. Although an immunodeficient state is considered to contribute to the pulmonary insufficiency which occurs after major trauma, convincing evidence of a lymphocyte-suppressive agent was found in only one patient.
1. This paper presents a series of 135 patients with displaced ankle fractures treated by rigid internal fixation followed by early joint exercises in bed until movements were restored and followed then by full weight bearing in a plaster. 2. The advantages obtained are as follows: A high standard of reduction can be achieved and maintained. The joint movements are established before organisation of the traumatic exudate. Weight bearing in a plaster reduces the degree of disability and prevents osteoporosis. Further remedial treatment after removal of the plaster is usually unnecessary. 3. All but five of the fractures (3·7 per cent) could be classified in the manner described by Lauge-Hansen. 4. This classification is the most satisfactory of those available and is recommended for general use. 5. Anatomical reduction was obtained in 102 patients (77 per cent), with good objective clinical results in 108 patients (82 per cent). 6. The quality of the clinical result depends mostly on the accuracy of the reduction, to a lesser extent on the degree of initial displacement, and least on the type of fracture. 7. It is considered that the traditional concept of diastasis requires modification; it is felt that the term lateral ankle instability, which includes low fracture of the fibula (intraosseous diastasis) is preferable. 8. Internal fixation of the syndesmosis is to be avoided except in rare instances. 9. The incidence of arthritis is shown to depend mostly upon the accuracy of reduction; the initial degree of displacement is also of importance.
1. The results of treatment of 100 consecutive patients with pertrochanteric and basal fractures of the femur treated by early operative fixation with a McKee two-piece nail and plate are reviewed. 2. Technical failures are analysed and discussed. 3. The pattern of mortality is discussed and contrasted with that in a comparable series of patients treated conservatively. 4. It is concluded that early operative fixation is the method of choice in the management of these fractures, and that the McKee pin and plate is a satisfactory and reliable device for securing internal fixation.
Aims. The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). Methods. This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan–Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality. Results.
Osteoporosis (OP) is a chronic metabolic bone disease characterized by the decrease of bone tissue per unit volume under the combined action of genetic and environmental factors, which leads to the decrease of bone strength, makes the bone brittle, and raises the possibility of
Objectives. MicroRNAs (miRNAs) have been reported as key regulators of bone formation, signalling, and repair. Fracture healing is a proliferative physiological process where the body facilitates the repair of a
Aims. The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb. Patients and Methods. An economic evaluation was conducted from the perspective of the United Kingdom NHS and Personal Social Services, based on evidence from the 460 participants in the Wound Management of Open Lower Limb
Aims. The aims of this study were to quantify health state utility
values (HSUVs) after a tibial fracture, investigate the effect of
complications, to determine the trajectory in HSUVs that result
in these differences and to quantify the quality-adjusted life years
(QALYs) experienced by patients. Patients and Methods. This is an analysis of 2138 tibial fractures enrolled in the
Fluid Lavage of Open Wounds (FLOW) and Study to Prospectively Evaluate
Reamed Intramedullary Nails in Patients with Tibial
Aims. Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees.
Aims. Although infrequent, a fracture of the cuboid can lead to significant
disruption of the integrity of the midfoot and its function. The
purpose of this study was to classify the pattern of fractures of
the cuboid, relate them to the mechanism of injury and suggest methods
of managing them. Patients and Methods. We performed a retrospective review of patients with radiologically
reported cuboid fractures.
