The results of meta-analysis show a revision rate of 33% for internal fixation of displaced fractures of the femoral neck, mostly because of nonunion. Osteopenia and osteoporosis are highly prevalent in elderly patients. Bone density has been shown to correlate with the intrinsic stability of the fixation of the fracture in cadaver and retrospective studies. We aimed to confirm or refute this finding in a clinical setting. We performed a prospective, multicentre study of 111 active patients over 60 years of age with a displaced fracture of the femoral neck which was eligible for internal fixation. The bone density of the femoral neck was measured pre-operatively by dual-energy x-ray absorptiometry (DEXA). The patients were divided into two groups namely, those with osteopenia (66%, mean T-score −1.6) and those with osteoporosis (34%, mean T-score −3.0). Age (p = 0.47), gender (p = 0.67), delay to surgery (p = 0.07), the angle of the fracture (p = 0.33) and the type of implant (p = 0.48) were similar in both groups. Revision to arthroplasty was performed in 41% of osteopenic and 42% of osteoporotic patients (p = 0.87). Morbidity (p = 0.60) and mortality were similar in both groups (p = 0.65). Our findings show that the clinical outcome of internal fixation for displaced fractures of the femoral neck does not depend on bone density and that pre-operative DEXA is not useful

We measured joint position sense in the knee by a new method which tests the proprioceptive contribution of the joint capsule and ligaments. The leg was supported on a splint, and held in several positions of flexion. The subjects' perception of the position was recorded on a visual analogue model and compared with the actual angle of flexion. Eighty-one normal and 45 osteoarthritic knees were examined, as were 10 knees with semi-constrained and 11 with hinged joint replacements. All were assessed with and without an elastic bandage around the knee. There was a steady decline in joint position sense with age in subjects with normal knees. Those with osteoarthritic knees had impaired joint position sense at all ages (p less than 0.001). Knee replacement improved the joint position sense slightly (p less than 0.02); semi-constrained replacement had a greater effect than hinged replacement. The effect of an elastic bandage in subjects with poor position sense was dramatic, improving accuracy by 40% (p less than 0.001). It is proposed that reduced proprioception in elderly and osteoarthritic subjects may be responsible for initiation or advancement of degeneration of the knee

One thousand and forty-two McKee-Farrar prostheses of the present design inserted in Norwich from January 1965 to December 1972 have been reviewed retrospectively to determine the incidence of complications needing revision. Of prostheses implanted for more than two years, 6.6 per cent needed revision for loosening (cup 35 per cent; stem 2.2 per cent; both components 0.9 per cent). Of the total number, 2.3 per cent became infected and 1.9 per cent dislocated. Most dislocations needed only a single closed reduction but 08 per cent were revised. The outcome of revision operations was also assessed. Of revisions for loosening, 40 per cent needed no further operation but 23 per cent required excision; pelvic fracture or bone destruction around the components made success unlikely. Revisions for dislocation were disappointing. Of all revisions 17 per cent became infected. Excision arthroplasty is better than a series of failed revisions in an elderly patient

1. One hundred and twenty cervical spines removed at routine necropsy from elderly patients dying in a general hospital have been examined. 2. There was some degree of degeneration of intervertebral discs in 110 cases–in forty-six this was severe. 3. Degenerative disc disease was found at an earlier age in men; mild damage preceded severe degeneration and collapse by about a decade. 4. Discs of the lower spine were most frequently and most severely affected. 5. Alterations of the normal cervical lordosis were produced by disc disease in thirty-two cases. 6. Osteoarthritis of the apophysial joints was found in seventy-eight, and by contrast to disc degeneration was commonest in the mid-cervical and upper cervical regions. In eighteen it was severe. 7. Degeneration and scarring of nerve roots was frequently associated with diseased discs; apophysial joint arthritis was found to be an important additional factor when it occurred in the lower cervical region. 8. No nerve root changes could be attributed to ischaemia resulting from narrowing or distortion of the vertebral arteries. 9. Cystic arachnoidal diverticula which excavate the posterior root ganglia were found in thirty-six cases

1. The average number of cases of osteogenic sarcoma found in the years 1946-58 inclusive in the northern division of the South-west Hospital region of England was 6·7 for each year, varying from three to ten. 2. The annual incidence of this sarcoma in this area was one tumour per 230,000 population. 3. These figures were compared with similar figures from Norway which indicate a rather similar tumour incidence among juveniles, but a very much smaller number of tumours in elderly persons. 4. Among the eighty-seven sarcomata collected in the specified area in thirteen years twenty-Six were associated with Paget's disease. 5. It is estimated that among the population of the specified area there were probably 26,000 persons at any time with Paget's disease, of whom one in 650 (0·15 per cent) would eventually develop sarcoma. 6. This study suggests that Paget's disease increases the risk of sarcoma about thirty-fold in persons over forty years of age. 7. It is tentatively suggested that the incidence of Paget's disease is influenced more by heredity than environment

Objectives

The aim of this study was to investigate the biomechanical effect of the anterolateral ligament (ALL), anterior cruciate ligament (ACL), or both ALL and ACL on kinematics under dynamic loading conditions using dynamic simulation subject-specific knee models.

We report a prospective study of the incidence of fractures in the adult population of Edinburgh, related to age and gender. Over a two-year period, 15 293 adults, 7428 males and 7865 females, sustained a fracture, and 5208 (34.0%) required admission. Between 15 and 49 years of age, males were 2.9 times more likely to sustain a fracture than females (95% CI 2.7 to 3.1). Over the age of 60 years, females were 2.3 times more likely to sustain a fracture than males (95% CI 2.1 to 2.4). There were three main peaks of fracture distribution: the first was in young adult males, the second was in elderly patients of both genders, mainly in metaphyseal bone such as the proximal femur, although diaphyseal fractures also showed an increase in incidence. The third increase in the incidence of fractures, especially of the wrist, was seen to start at 40 years of age in women. Our study has also shown that ‘osteoporotic’ fractures became evident in women earlier than expected, and that they were not entirely a postmenopausal phenomenon

In a prospective, controlled study, we measured the effect on cardiac output of the introduction of methylmethacrylate during hemiarthroplasty for displaced fractures of the femoral neck. We treated 20 elderly patients who were similar in age, height, weight and preoperative left ventricular function with either cemented or uncemented hemiarthroplasty. Using a transoesophageal Doppler probe, we measured cardiac output before incision and at six stages of the procedure: during the surgical approach, reaming and lavage of the femoral canal, the introduction of cement, the insertion of the prosthesis, and in reduction and closure. We found that before the cement was introduced, there was no difference in stroke volume or cardiac output (p > 0.25). Cementation produced a transient but significant reduction in cardiac output of 33% (p < 0.01) and a reduction in stroke volume of 44% (p < 0.02). The introduction of cement did not affect the heart rate or mean arterial pressure. There was no significant difference in cardiac function on insertion of the prosthesis. Standard non-invasive haemodynamic monitoring did not detect the cardiovascular changes which may account for the sudden deaths that sometimes occur during cemented hemiarthroplasty. The fall in stroke volume and cardiac output may be caused by embolism occurring during cementation, but there was no similar fall during reaming or insertion of the prosthesis

We have reviewed 36 of 39 consecutive patients with an average age of 68 years who had semiconstrained elbow replacement for distal humeral nonunion at an average follow-up of 50.4 months (24 to 127). Of these, 31 (86%) had satisfactory results, three (8%) had fair, and two (6%) had poor results; 32 patients (88%) had moderate or severe pain before and 91% had no or only mild discomfort after the procedure. Motion had improved from a mean arc of 29 degrees to 103 degrees before operation to 16 degrees to 127 degrees after surgery. All five flail extremities were stable at last assessment. There were seven complications (18%): two patients had deep infection, two had particulate synovitis, two had ulnar neuropathy and one had worn polyethylene bushes. Five of these seven, excluding the two with transient nueropathy, required reoperation (13%). Joint replacement arthroplasty can be a safe and reliable treatment for this difficult clinical condition, seen most commonly in elderly patients. This is a significant advance, since repeated osteosynthesis has been shown to be ineffective in most patients

1. The appearance of decalcified bone matrix in the electron microscope is described. 2. In the matrix two types of collagen fibril have been distinguished. Differences observed are in solubility, x-ray diffraction pattern and appearance. In infant bone the form which appears as fine fibrils predominates. In adult bone the form which appears as tubular fibrils of larger diameter predominates. 3. In bones from elderly subjects the chemical reaction employed to convert collagen into eucollagen sometimes hydrolyses fatty acid esters, and lines due to the free fatty acid are found on the x-ray diffraction patterns of the insoluble residue after citrate extraction. 4. In ancient bones and fossils the stable tubular form of collagen survives, but not the fine fibrils. 5. When decalcified, the matrix in osteoporotic bones loses its architecture and fibrillar form. Under conditions in which only a small fraction is dissolved from normal bone most of the collagen in osteoporotic bone disperses in citric acid. The insoluble residue then gives a modified x-ray diffraction pattern. 6. Evidence has been produced to suggest that the immediate cause of many forms of osteoporosis is some local factor affecting the osteocytes, rather than a general chemical effect

We have investigated whether control of balance is improved during stance and gait and sit-to-stand tasks after unilateral total hip replacement undertaken for osteoarthritis of the hip. We examined 25 patients with a mean age of 67 years (. sd. 6.2) before and at four and 12 months after surgery and compared the findings with those of 50 healthy age-matched control subjects. For all tasks, balance was quantified using angular measurements of movement of the trunk. Before surgery, control of balance during gait and sit-to-stand tasks was abnormal in patients with severe osteoarthritis of the hip, while balance during stance was similar to that of the healthy control group. After total hip replacement, there was a progressive improvement at four and 12 months for most gait and sit-to-stand tasks and in the time needed to complete them. By 12 months, the values approached those of the control group. However, trunk pitch (forwards-backwards) and roll (side-to-side) velocities were less stable (greater than the control) when walking over barriers as was roll for the sit-to-stand task, indicative of a residual deficit of balance. Our data suggest that patients with symptomatic osteoarthritis of the hip have marked deficits of balance in gait tasks, which may explain the increased risk of falling which has been reported in some epidemiological studies. However, total hip replacement may help these patients to regain almost normal control of balance for some gait tasks, as we found in this study. Despite the improvement in most components of balance, however, the deficit in the control of trunk velocity during gait suggests that a cautious follow-up is required after total hip replacement regarding the risk of a fall, especially in the elderly

Aims

The aims of this study were to determine the rates of surgical complications, reoperations, and readmissions following herniated lumbar disc surgery, and to investigate the impact of sociodemographic factors and comorbidity on the rate of such unfavourable events.

1. Senile osteoporosis is one of the common causes of morbidity in old people. Its distribution in European and American populations has been deduced from epidemiological studies of its major complications, such as fractures of the vertebrae and the femoral neck. Although there has been some evidence that different population groups differ in their susceptibility to this condition, no demographic study of its prevalence in the white and Bantu races has previously been made. 2. The present paper describes an epidemiological study of femoral neck fractures in the Bantu population of Johannesburg, covering the years 1957-63. The cases were analysed by age and sex, the type of trauma and the level of the fracture. The number of fractures was related to the population at risk; the fracture incidence was expressed both as an age-specific rate and as a standardised rate and compared with fracture rates in European populations. It was found that the fracture rate in the elderly Bantu is less than one-tenth of that in Western European populations, and that males and females are affected equally. It was concluded that senile or post-menopausal osteoporosis is much less pronounced in the Bantu than in white populations. 3. The relationship of these findings to endocrine changes, calcium balance and racial factors is discussed. It is suggested that senile osteoporosis is not caused by a simple calcium deficiency but may be related to an imbalance between calcium intake, absorption and excretion, or a failure of the complex mechanism which normally controls this balance. Whatever the immediate cause, however, race plays an important part in determining the onset and distribution of the condition

Objectives

Up to 10% of fractures result in undesirable outcomes, for which female sex is a risk factor. Cellular sex differences have been implicated in these different healing processes. Better understanding of the mechanisms underlying bone healing and sex differences in this process is key to improved clinical outcomes. This study utilized a macrophage–mesenchymal stem cell (MSC) coculture system to determine: 1) the precise timing of proinflammatory (M1) to anti-inflammatory (M2) macrophage transition for optimal bone formation; and 2) how such immunomodulation was affected by male versus female cocultures.

Aims

We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis.

The case histories of 361 subcapital fractures of the femoral neck in 354 patients treated by primary replacement with the cemented Thompson prosthesis were reviewed, and 156 survivors were seen at follow-up. The average age was eighty-one years. Three hundred and thirty fractures occurred in women and thirty-one in men. The antero-lateral approach to the hip was used at all operations because it allows immediate and unrestricted mobilisation after operation. It is considered that this method is the best treatment in the rehabilitation of elderly patients after high femoral neck fractures, because of its low morbidity and high success rate in returning the geriatric orthopaedic patient to independence. The results after an average of just over three years were available for 161 hips in 156 patients studied at follow-up. Of these, 132 (82 per cent) were satisfactory. Most of the unsatisfactory results were in patients under seventy-five years of age. Out of the whole group of 361 hips treated the important early complications were wound infections in seventeen hips 4-7 per cent), all of which resolved, and dislocation in seven hips (2 per cent). Forty-six patients (12-9 per cent) died during the first four weeks after operation, their average age being eighty-five. One hundred and seventy-one patients (47-4 per cent) were discharged from hospital within under four weeks of the operation. Acetabular erosion and loosening are shown to be the important later complications. Three patients had late sepsis

Cases are reported of two men who sustained bilateral hip injuries while undergoing convulsive therapy and of one woman who sustained bilateral hip injuries during a uraemic convulsion. A further twenty-three previously unreported cases are analysed, sixteen of which were of simultaneous bilateral femoral neck fractures and five of which were simultaneous bilateral central dislocations of the hip. One other patient sustained his injuries in an epileptic fit. A review of the literature has revealed another thirty-five cases of bilateral hip injuries, most of them caused by convulsive therapy, but a few by accident, disease of the femoral neck, or epilepsy. One case is included of a rare double injury, a femoral neck fracture on one side and a central dislocation on the other. I have found no previous reference to this combined injury. Double hip injuries are very rare in relation to the large numbers of patients receiving convulsion therapy, but the change from pharmacological to electrical methods has not prevented their occurrence and at least fifteen are known to have occurred during the last six years. A wide age range is represented, and many fractures of convulsive origin have occurred in fit, well nourished, adult men. Only a few have been found in more elderly and possibly osteoporotic patients. All the "convulsive " injuries were sustained during unmodified treatment, and mention is made of the differences of opinion among psychiatrists about the use of anaesthesia and of relaxant drugs in convulsion therapy. These are the most severe injuries complicating convulsion therapy, and the most difficult for the orthopaedic surgeon to treat

1. Fifty cases of arthrodesis of the hip joint in tuberculous arthritis are analysed; in forty cases the late end-result has been ascertained two or more years after operation. 2. The indications for arthrodesis are discussed. The operation should not be performed when disease is active; it should not be undertaken before the age of twelve to thirteen years; it is not advisable in elderly patients; it may be contra-indicated when there are multiple foci of infection. Subject to these limitations every patient with unsound ankylosis after adequate conservative treatment should be treated by arthrodesis; painful fibrous ankylosis and late onset of deformity are definite indications. 3. Three types of operation have been used: intra-articular arthrodesis; extra-articular ilio-femoral arthrodesis; combined intra- and extra-articular arthrodesis. Extra-articular ilio-femoral arthrodesis is preferred, deformity being first corrected by traction or osteotomy. 4. Post-operation complications were few; the mortality rate was low (2 per cent.). 5. There was bone ankylosis with solid incorporation of the graft in 87·5 per cent., failure of union of the graft (to the trochanter) in 10 per cent., and destruction of the graft in 2·5 per cent. 6. Late end-results show full working capacity in 87·5 per cent. of patients, part working capacity in 2·5 per cent. and inability to work in 7·5 per cent. The writer wishes to express his thanks to Professor Harry Platt and Professor T. P.. McMurray for criticism and advice in the preparation of this paper, and to Dr F. C. S. Bradbury, Central Consultant Tuberculosis Officer of the Lancashire County Council, for permission to publish these cases