Between 1994 and 1999, we treated six patients with
We have carried out a prospective study of 17 patients (14 women, 3 men) of mean age 48 years (21 to 76) with transcervical fractures of the femur using MRI to detect early evidence of
Controversy surrounds the management of displaced
three- and four-part fractures of the proximal humerus. The percutaneous
Resch technique of stabilisation involves minimal soft-tissue dissection
and a reduced risk of stiffness and
Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9). Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of
Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic.Aims
Methods
There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively.Aims
Methods
Untreated 3- and 4-part fractures of the proximal humerus have a poor functional outcome. Open operation increases the risk of
The aim of this study was to determine the comorbid risk factors for failure in young patients who undergo fixation of a displaced fracture of the femoral neck. We identified from a prospective database all such patients ≤ 60 years of age treated with reduction and internal fixation. The main outcome measures were union, failure of fixation, nonunion and the development of
A consecutive series of 320 patients with an
intracapsular fracture of the hip treated with a dynamic locking
plate (Targon Femoral Neck (TFN)) were reviewed. All surviving patients
were followed for a minimum of two years. During the follow-up period
109 patients died. There were 112 undisplaced fractures, of which three (2.7%) developed
nonunion or re-displacement and five (4.5%) developed avascular
necrosis of the femoral head. Revision to an arthroplasty was required
for five patients (4.5%). A further six patients (5.4%) had elective
removal of the plate and screws. There were 208 displaced fractures, of which 32 (15.4%) developed
nonunion or re-displacement and 23 (11.1%) developed
Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic
Our aim was to determine the effect of the initial pattern of fracture and the displacement of fragments on the outcome of proximal humeral fractures treated conservatively. We followed 93 consecutive patients prospectively for one year. Final movement and strength were compared with those of the contralateral side. The final American Shoulder and Elbow Society score and the Disabilities of Arm, Shoulder and Hand and Short-Form 36 questionnaires were compared with those provided by the patient on the day of the injury. Radiographs and CT scans with three-dimensional reconstruction were obtained in all patients. The pattern of the fracture and the displacement of individual fragments were analysed and correlated with the final outcome. There were two cases of nonunion and six of
Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (>
95%). The arthrodesis failed because of
Aims. The treatment of late presenting fractures of the lateral humeral
condyle in children remains controversial. . Methods. We report on the outcome for 16 children who presented with a
fracture of the lateral humeral epicondyle at a mean of 7.4 weeks
(3 to 15.6) after injury and were treated surgically. Results. The mean follow-up was four years (1.1 to 8.9), at which time
the mean age of the patients was 8.7 years (3.2 to 17.8). . The mean Dhillon functional score improved from 3.3 to 5.6 and
the mean overall scores improved from 5.6 to 8.5. . A total of seven patients had a fishtail deformity and eight
had partial lateral epiphyseal closure. None had
Hip fractures in patients < 60 years old currently account for only 3% to 4% of all hip fractures in England, but this proportion is increasing. Little is known about the longer-term patient-reported outcomes in this potentially more active population. The primary aim is to examine patient-reported outcomes following isolated hip fracture in patients aged < 60 years. The secondary aim is to determine an association between outcomes and different types of fracture pattern and/or treatment implants. All hip fracture patients aged 18 to 60 years admitted to a single centre over a 15-year period were used to identify the study group. Fracture pattern (undisplaced intracapsular, displaced intracapsular, and extracapsular) and type of operation (multiple cannulated hip screws, angular stable fixation, hemiarthroplasty, and total hip replacement) were recorded. The primary outcome measures were the Oxford Hip Score (OHS), the EuroQol five-dimension questionnaire (EQ-5D-3L), and EQ-visual analogue scale (VAS) scores. Preinjury scores were recorded by patient recall and postinjury scores were collected at a mean of 57 months (9 to 118) postinjury. Ethics approval was obtained prior to study commencement.Aims
Methods
Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no
We have compared the results and complications after closed and open reduction with internal fixation in young adults with displaced intracapsular fractures (Garden grades III and IV) of the neck of the femur. We also studied the risk factors which influenced nonunion and the development of
In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 ± 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of
In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries. Between January 2014 and April 2016, all patients with an isolated, nonoperatively treated one-part proximal humerus fracture were prospectively followed up. Clinical and radiological evaluation took place at less than two, six, 12, and 52 weeks. Fracture configuration, bone quality, and comminution were determined on the initial radiographs. Fracture healing, secondary displacement, and treatment changes were recorded during follow-up.Aims
Patients and Methods
Neglected fractures of the femoral neck, common in young adults in underdeveloped countries, may be complicated by nonunion or
The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery. A total of 17 DBM products were used as search terms in two available databases: Embase and PubMed according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement. All articles that reported the clinical use of a DBM-product in trauma and orthopaedic related surgery were included.Objectives
Methods
Outcome measures quantifying aspects of health in a precise,
efficient, and user-friendly manner are in demand. Computer adaptive
tests (CATs) may overcome the limitations of established fixed scales
and be more adept at measuring outcomes in trauma. The primary objective
of this review was to gain a comprehensive understanding of the
psychometric properties of CATs compared with fixed-length scales
in the assessment of outcome in patients who have suffered trauma
of the upper limb. Study designs, outcome measures and methodological
quality are defined, along with trends in investigation. A search of multiple electronic databases was undertaken on 1
January 2017 with terms related to “CATs”, “orthopaedics”, “trauma”,
and “anatomical regions”. Studies involving adults suffering trauma
to the upper limb, and undergoing any intervention, were eligible.
Those involving the measurement of outcome with any CATs were included.
Identification, screening, and eligibility were undertaken, followed
by the extraction of data and quality assessment using the Consensus-Based
Standards for the Selection of Health Measurement Instruments (COSMIN) criteria.
The review is reported according to the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) criteria and reg istered (PROSPERO: CRD42016053886).Aims
Materials and Methods
In the time since Letournel popularised the surgical
treatment of acetabular fractures, more than 25 years ago, there
have been many changes within the field, related to patients, surgical
technique, implants and post-operative care. However, the long-term
outcomes appear largely unchanged. Does this represent stasis or
have the advances been mitigated by other negative factors? In this
article we have attempted to document the recent changes within
the surgery of patients with a fracture involving the acetabulum,
outline contemporary management, and identify the major problem
areas where further research is most needed. Cite this article:
To evaluate the outcomes of cemented total hip arthroplasty (THA)
following a fracture of the acetabulum, with evaluation of risk
factors and comparison with a patient group with no history of fracture. Between 1992 and 2016, 49 patients (33 male) with mean age of
57 years (25 to 87) underwent cemented THA at a mean of 6.5 years
(0.1 to 25) following acetabular fracture. A total of 38 had undergone
surgical fixation and 11 had been treated non-operatively; 13 patients
died at a mean of 10.2 years after THA (0.6 to 19). Patients were
assessed pre-operatively, at one year and at final follow-up (mean
9.1 years, 0.5 to 23) using the Oxford Hip Score (OHS). Implant
survivorship was assessed. An age and gender-matched cohort of THAs
performed for non-traumatic osteoarthritis (OA) or avascular necrosis
(AVN) (n = 98) were used to compare complications and patient-reported outcome
measures (PROMs).Aims
Patients and Methods
The aims of this study were to determine the cumulative ten-year
survivorship of hips treated for acetabular fractures using surgical
hip dislocation and to identify factors predictive of an unfavourable
outcome. We followed up 60 consecutive patients (61 hips; mean age 36.3
years, standard deviation (Aims
Patients and Methods
To compare the outcomes for trochanteric fractures treated with
a sliding hip screw (SHS) or a cephalomedullary nail. A total of 400 patients with a trochanteric hip fracture were
randomised to receive a SHS or a cephalomedullary nail (Targon PFT).
All surviving patients were followed up to one year from injury.
Functional outcome was assessed by a research nurse blinded to the
implant used.Aims
Patients and Methods
The spiral blade modification of the Dynamic
Hip Screw (DHS) was designed for superior biomechanical fixation
in the osteoporotic femoral head. Our objective was to compare clinical
outcomes and in particular the incidence of loss of fixation. In a series of 197 consecutive patients over the age of 50 years
treated with DHS-blades (blades) and 242 patients treated with conventional
DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were
identified from a prospectively compiled database in a level 1 trauma
centre. Using propensity score matching, two groups comprising 177
matched patients were compiled and radiological and clinical outcomes
compared. In each group there were 66 males and 111 females. Mean
age was 83.6 (54 to 100) for the conventional DHS group and 83.8
(52 to 101) for the blade group. Loss of fixation occurred in two blades and 13 DHSs. None of
the blades had observable migration while nine DHSs had gross migration
within the femoral head before the fracture healed. There were two
versus four implant cut-outs respectively and one side plate pull-out
in the DHS group. There was no significant difference in mortality
and eventual walking ability between the groups. Multiple logistic
regression suggested that poor reduction (odds ratio (OR) 11.49,
95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation
by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent
predictors of loss of fixation. The spiral blade design may decrease the risk of implant migration
in the femoral head but does not reduce the incidence of cut-out
and reoperation. Reduction of the fracture is of paramount importance
since poor reduction was an independent predictor for loss of fixation
regardless of the implant being used. Cite this article:
A pragmatic multicentre randomised controlled trial (PROFHER)
was conducted in United Kingdom National Health Service (NHS) hospitals
to evaluate the clinical effectiveness and cost effectiveness of
surgery compared with non-surgical treatment for displaced fractures
of the proximal humerus involving the surgical neck in adults. A cost utility analysis from the NHS perspective was performed.
Differences between surgical and non-surgical treatment groups in
costs and quality adjusted life years (QALYs) at two years were
used to derive an estimate of the cost effectiveness of surgery
using regression methods. Aims
Methods
Coronal plane fractures of the posterior femoral
condyle, also known as Hoffa fractures, are rare. Lateral fractures are
three times more common than medial fractures, although the reason
for this is not clear. The exact mechanism of injury is likely to
be a vertical shear force on the posterior femoral condyle with
varying degrees of knee flexion. These fractures are commonly associated
with high-energy trauma and are a diagnostic and surgical challenge. Hoffa
fractures are often associated with inter- or supracondylar distal
femoral fractures and CT scans are useful in delineating the coronal
shear component, which can easily be missed. There are few recommendations
in the literature regarding the surgical approach and methods of
fixation that may be used for this injury. Non-operative treatment
has been associated with poor outcomes. The goals of treatment are
anatomical reduction of the articular surface with rigid, stable
fixation to allow early mobilisation in order to restore function.
A surgical approach that allows access to the posterior aspect of
the femoral condyle is described and the use of postero-anterior
lag screws with or without an additional buttress plate for fixation
of these difficult fractures. Cite this article:
We compared a new fixation system, the Targon
Femoral Neck (TFN) hip screw, with the current standard treatment of
cannulated screw fixation. This was a single-centre, participant-blinded,
randomised controlled trial. Patients aged 65 years and over with
either a displaced or undisplaced intracapsular fracture of the
hip were eligible. The primary outcome was the risk of revision
surgery within one year of fixation. A total of 174 participants were included in the trial. The absolute
reduction in risk of revision was of 4.7% (95% CI 14.2 to 22.5)
in favour of the TFN hip screw (chi-squared test, p = 0.741), which
was less than the pre-specified level of minimum clinically important
difference. There were no significant differences in any of the
secondary outcome measures. We found no evidence of a clinical difference in the risk of
revision surgery between the TFN hip screw and cannulated screw
fixation for patients with an intracapsular fracture of the hip. Cite this article:
In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function. Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck.
Early total hip replacement (THR) for acetabular
fractures offers accelerated rehabilitation, but a high risk of heterotopic
ossification (HO) has been reported. The purpose of this study was
to evaluate the incidence of HO, its associated risk factors and
functional impact. A total of 40 patients with acetabular fractures
treated with a THR weres retrospectively reviewed. The incidence
and severity of HO were evaluated using the modified Brooker classification,
and the functional outcome assessed. The overall incidence of HO
was 38%
(n = 15), with nine severe grade III cases. Patients who underwent
surgery early after injury had a fourfold increased chance of developing
HO. The mean blood loss and operating time were more than twice
that of those whose surgery was delayed (p = 0.002 and p <
0.001,
respectively). In those undergoing early THR, the incidence of grade
III HO was eight times higher than in those in whom THR was delayed
(p = 0.01). Only three of the seven patients with severe HO showed
good or excellent Harris hip scores compared with eight of nine
with class 0, I or II HO (p = 0.049). Associated musculoskeletal
injuries, high-energy trauma and head injuries were associated with
the development of grade III HO. The incidence of HO was significantly higher in patients with
a displaced acetabular fracture undergoing THR early compared with
those undergoing THR later and this had an adverse effect on the
functional outcome. Cite this article:
The use of pulsed electromagnetic fields (PEMF)
to stimulate bone growth has been recommended as an alternative to
the surgical treatment of ununited scaphoid fractures, but has never
been examined in acute fractures. We hypothesised that the use of
PEMF in acute scaphoid fractures would accelerate the time to union
by 30% in a randomised, double-blind, placebo-controlled, multicentre
trial. A total of 53 patients in three different medical centres
with a unilateral undisplaced acute scaphoid fracture were randomly
assigned to receive either treatment with PEMF (n = 24) or a placebo
(n = 29). The clinical and radiological outcomes were assessed at
four, six, nine, 12, 24 and 52 weeks. A log-rank analysis showed that neither time to clinical and
radiological union nor the functional outcome differed significantly
between the groups. The clinical assessment of union indicated that
at six weeks tenderness in the anatomic snuffbox (p = 0.03) as well
as tenderness on longitudinal compression of the scaphoid (p = 0.008) differed
significantly in favour of the placebo group. We conclude that stimulation of bone growth by PEMF has no additional
value in the conservative treatment of acute scaphoid fractures.
Corticosteroid use has been implicated in the
development of osteonecrosis of the femoral head (ONFH). The exact mechanism
and predisposing factors such as age, gender, dosage, type and combination
of steroid treatment remain controversial. Between March and July
2003, a total of 539 patients with severe acute respiratory syndrome (SARS)
were treated with five different types of steroid. There were 129
men (24%) and 410 women (76%) with a mean age of 33.7 years (21
to 59). Routine screening was undertaken with radiographs, MRI and/or
CT to determine the incidence of ONFH. Of the 129 male patients with SARS, 51 (39.5%) were diagnosed
as suffering from ONFH, compared with only 79 of 410 female patients
(19.3%). The incidence of ONFH in the patients aged between 20 and
49 years was much higher than that of the group aged between 50
and 59 years (25.9% (127 of 491) Cite this article:
In a randomised trial involving 598 patients
with 600 trochanteric fractures of the hip, the fractures were treated with
either a sliding hip screw (n = 300) or a Targon PF intramedullary
nail (n = 300). The mean age of the patients was 82 years (26 to
104). All surviving patients were reviewed at one year with functional
outcome assessed by a research nurse blinded to the treatment used.
The intramedullary nail was found to have a slightly increased mean
operative time (46 minutes ( In summary, both implants produced comparable results but there
was a tendency to better return of mobility for those treated with
the intramedullary nail.
We report the outcome of 161 of 257 surgically fixed acetabular fractures. The operations were undertaken between 1989 and 1998 and the patients were followed for a minimum of ten years. Anthropometric data, fracture pattern, time to surgery, associated injuries, surgical approach, complications and outcome were recorded. Modified Merle D’Aubigné score and Matta radiological scoring systems were used as outcome measures. We observed simple fractures in 108 patients (42%) and associated fractures in 149 (58%). The result was excellent in 75 patients (47%), good in 41 (25%), fair in 12 (7%) and poor in 33 (20%). Poor prognostic factors included increasing age, delay to surgery, quality of reduction and some fracture patterns. Complications were common in the medium- to long-term and functional outcome was variable. The gold-standard treatment for displaced acetabular fractures remains open reduction and internal fixation performed in dedicated units by specialist surgeons as soon as possible.
We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome. We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables. The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of >
2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged >
50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement.
We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities. We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D). There was a significant reduction in level of activity, frequency of participation in sport (both p <
0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation.
We describe a series of 20 patients with ununited fractures of the femoral neck following neglected trauma or failed primary internal fixation who were seen at a mean of 7.5 months (2 to 18) following injury. Open reduction and internal fixation of the fracture was performed in all patients, together with a myoperiosteal flap on the quadratus femoris muscle pedicle. Union occurred at a mean of 4.9 months (2 to 10) in all patients. The mean follow-up was for 70 months (14 to 144). There was no further progression in six of seven patients with pre-operative radiological evidence of osteonecrosis of the femoral head. One patient had delayed collapse and flattening of the femoral head ten years after union of the fracture, but remained asymptomatic. This study demonstrates the orthopaedic application of myoperiosteal grafting for inducing osteogenesis in a difficult clinical situation.
We aimed to identify variables associated with clinical and radiological outcome following fractures of the acetabulum associated with posterior dislocation of the hip. Using a prospective database of 1076 such fractures, we identified 109 patients with this combined injury managed operatively within three weeks and followed up for two or more years. The patients had a mean age of 42 years (15 to 79), 78 (72%) were male, and 84 (77%) had been involved in motor vehicle accidents. Using multivariate analysis the quality of reduction of the fracture was identified as the only significant predictor of radiological grade, clinical function and the development of post-traumatic arthritis (p <
0.001). All patients lacking anatomical reduction developed arthritis whereas only 25.5% (24 patients) with an anatomical reduction did so (p = 0.05). The quality of the reduction of the fracture is the most important variable in forecasting the outcome for patients with this injury. The interval to reduction of the dislocation of the hip may be less important than previously described.
The surgical treatment of three- and four-part fractures of the proximal humerus in osteoporotic bone is difficult and there is no consensus as to which technique leads to the best outcome in elderly patients. Between 1998 and 2004 we treated 76 patients aged over 70 years with three- or four-part fractures by percutaneous reduction and internal fixation using the Humerusblock. A displacement of the tuberosity of >
5 mm and an angulation of >
30° of the head fragment were the indications for surgery. Of the patients 50 (51 fractures) were available for follow-up after a mean of 33.8 months (5.8 to 81). The absolute, age-related and side-related Constant scores were recorded. Of the 51 fractures, 46 (90.2%) healed primarily. Re-displacement of fragments or migration of Kirschner wires was seen in five cases. Necrosis of the humeral head developed in four patients. In three patients a secondary arthroplasty had to be performed, in two because of re-displacement and in one for necrosis of the head. There was one case of deep infection which required a further operation and one of delayed healing. The mean Constant score of the patients with a three-part fracture was 61.2 points (35 to 87) which was 84.9% of the score for the non-injured arm. In four-part fractures it was 49.5 points (18 to 87) or 68.5% of the score for the non-injured arm. The Humerusblock technique can provide a comfortable and mobile shoulder in elderly patients and is a satisfactory alternative to replacement and traditional techniques of internal fixation.
Secure fixation of displaced proximal fractures of the humerus is a challenging problem. A total of 32 patients with acutely displaced three- or four-part proximal fractures of the humerus were treated by open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate. There were 23 women and nine men with a mean age of 59.9 years (18 to 87). Data were collected prospectively and the outcomes were assessed using the Constant score. The mean follow-up was for 11 months (3 to 24). In 31 patients (97%) the fracture united clinically and radiologically at a mean of 10 weeks (8 to 24). The mean Constant score at final review was 66.5 (30 to 92). There was no significant difference in outcome when comparing patients aged more than 60 years (18 patients) with those aged less than 60 years (14 patients) ( This plate provides an alternative method of fixation for fractures of the proximal humerus. It provides a stable fixation in young patients with good-quality bone sufficient to permit early mobilisation. Failure of the screws to maintain fixation in the elderly remains a problem.
A delay in establishing the diagnosis of an occult
fracture of the hip that remains unrecognised after plain radiography
can result in more complex treatment such as an arthroplasty being
required. This might be avoided by earlier diagnosis using MRI.
The aim of this study was to investigate the best MR imaging sequence
for diagnosing such fractures. From a consecutive cohort of 771
patients admitted between 2003 and 2011 with a clinically suspected
fracture of the hip, we retrospectively reviewed the MRI scans of
the 35 patients who had no evidence of a fracture on their plain
radiographs. In eight of these patients MR scanning excluded a fracture
but the remaining 27 patients had an abnormal scan: one with a fracture
of the pubic ramus, and in the other 26 a T1-weighted
coronal MRI showed a hip fracture with 100% sensitivity. T2-weighted
imaging was undertaken in 25 patients, in whom the diagnosis could
not be established with this scanning sequence alone, giving a sensitivity
of 84.0% for T2-weighted imaging. If there is a clinical suspicion of a hip fracture with normal
radiographs, T1-weighted coronal MRI is the best sequence
of images for identifying a fracture.
There remains uncertainty about the most effective surgical approach in the treatment of complex fractures of the acetabulum. We have reviewed the experience of a single surgeon using the extended iliofemoral approach, as described by Letournel. A review of the database of such fractures identified 106 patients operated on using this approach with a minimum follow-up of two years. All data were collected prospectively. The fractures involved both columns in 64 (60%). Operation was undertaken in less than 21 days after injury in 71 patients (67%) and in 35 (33%) the procedure was carried out later than this. The reduction of the fracture was measured on plain radiographs taken after operation and defined as anatomical (0 to 1 mm of displacement); imperfect (2 to 3 mm) or poor (>
3 mm). The functional outcome was measured by the modified Merle d’Aubigné and Postel score. The mean follow-up was for 6.3 years (2 to 17). All patients achieved union of the fractures. The reduction was graded as anatomical in 76 (72%) of the patients, imperfect in 23 (22%), and poor in six (6%). The mean Merle d’Aubigné and Postel score was 15 (5 to 18) with 68 patients (64%) showing good or excellent and 38 (36%) fair or poor results. Function correlated significantly with the accuracy of the reduction (p <
0.009). Significant heterotopic ossification developed in 32 patients (30%) and was associated with a worse mean Merle d’Aubigné and Postel score of 13.7. The extended iliofemoral approach can be performed safely in selected complex acetabular fractures with an acceptable clinical outcome and rate of complications. Effective prophylaxis against heterotopic ossification should be strongly considered.
Over a five-year period, adult patients with
marginal impaction of acetabular fractures were identified from
a registry of patients who underwent acetabular reconstruction in
two tertiary referral centres. Fractures were classified according
to the system of Judet and Letournel. A topographic classification
to describe the extent of articular impaction was used, dividing
the joint surface into superior, middle and inferior thirds. Demographic information,
hospitalisation and surgery-related complications, functional (EuroQol
5-D) and radiological outcome according to Matta’s criteria were
recorded and analysed. In all, 60 patients (57 men, three women)
with a mean age of 41 years (18 to 72) were available at a mean
follow-up of 48 months (24 to 206). The quality of the reduction
was ‘anatomical’ in 44 hips (73.3%) and ‘imperfect’ in 16 (26.7%).
The originally achieved anatomical reduction was lost in Univariate linear regression analysis of the functional outcome
showed that factors associated with worse pain were increasing age
and an inferior location of the impaction. Elevation of the articular
impaction leads to joint preservation with satisfactory overall
medium-term functional results, but secondary collapse is likely
to occur in some patients. Cite this article:
We reviewed 59 bone graft substitutes marketed
by 17 companies currently available for implantation in the United Kingdom,
with the aim of assessing the peer-reviewed literature to facilitate
informed decision-making regarding their use in clinical practice.
After critical analysis of the literature, only 22 products (37%)
had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita),
Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question
the need for so many different products, especially with limited
published clinical evidence for their efficacy, and conclude that
there is a considerable need for further prospective randomised
trials to facilitate informed decision-making with regard to the
use of current and future bone graft substitutes in clinical practice. Cite this article:
We prospectively analysed the epidemiology of acetabular fractures over a period of 16 years in order to identify changes in their incidence or other demographic features. Our study cohort comprised a consecutive series of 351 patients with acetabular fractures admitted to a single institution between January 1988 and December 2003. There was no significant change in the overall incidence of acetabular fractures, which remained at 3 patients/100 000/year. There was, however, a significant reduction in the number of men sustaining an acetabular fracture over the period (p <
0.02). The number of fractures resulting from falls from a height <
10 feet showed a significant increase (p <
0.002), but there was no change in those caused by motor-vehicle accidents. There was a significant reduction in the median Injury Severity score over the period which was associated with a significant decrease in mortality (p <
0.04) and a reduction in the length of hospital stay. The incidence of osteoarthritis noted during follow-up of operatively-treated fractures declined from 31% to 14%, reflecting improved results with increasing subspecialisation. Our findings suggest that there will be a continuing need for some orthopaedic surgeons to specialise in the management of these fractures. In addition, the reductions in the Injury Severity score and mortality may be associated with improved road and vehicle safety.
We have reviewed 20 women and three men aged 22 to 73 years, who had sustained a Mason type-IIb fracture of the neck of the radius 14 to 25 years earlier. There were 19 patients with displacement of the fractures of 2 mm to 4 mm, of whom 13 had been subjected to early mobilisation and six had been treated in plaster for one to four weeks. Of four patients with displacement of 4 mm to 8 mm, three had undergone excision and one an open reduction of the head of radius. A total of 21 patients had no subjective complaints at follow-up, but two had slight impairment and occasional elbow pain. The mean range of movement and strength of the elbow were not impaired. The elbows had a higher prevalence of degenerative changes than the opposite side, but no greater reduction of joint space. Mason type-IIb fractures have an excellent long-term outcome if operation is undertaken when the displacement of the fracture exceeds 4 mm.
We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58). The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly.
Incomplete intertrochanteric fractures do not extend across to the medial femoral cortex and are stable, without rotational deformity or shortening of the lower limb. The aim of our study was to establish whether they can be successfully managed conservatively. A total of 68 patients over a five-year period presented with a suspected fracture of the femoral neck and underwent an MRI scan for further assessment. From these, we retrospectively reviewed eight patients with normal plain radiographs but with an incomplete, intertrochanteric fracture on MRI scan. Five were managed conservatively and three operatively. The mean length of hospital stay was 16 days for the conservatively-treated group and 15 days for those who underwent surgery; this was not statistically significant (p >
0.5) and all patients were mobilised on discharge. Although five patients were readmitted at a mean of 3.2 years after discharge, none had progressed to a complete fracture. We believe that patients with incomplete intertrochanteric fractures should be considered for conservative treatment.
We have treated 14 patients (15 fractures) with nonunion of an intra-articular fracture of the body of the calcaneum. The mean follow-up was six years (2 to 8.5). A total of 14 fractures (93%) had initially been treated operatively with 12 (86%) having non-anatomical reductions. Four feet (27%) had concomitant osteomyelitis. Of the nonunions, 14 (93%) went on to eventual union after an average of two reconstructive procedures. All underwent bone grafting of the nonunion. The eventual outcome was a subtalar arthrodesis in ten (67%) cases, a triple arthrodesis in four (27%) and a nonunion in one (6%). Three patients had a wound dehiscence; all required a local rotation flap. The mean American Orthopaedic Foot and Ankle Society score at latest follow-up was 69, and the mean Visual analogue scale was 3. Of those who were initially employed, 82% (9 of 11) eventually returned to work. We present an algorithm for the treatment of calcaneal nonunion, and conclude that despite a relatively high rate of complication, this complex surgery has a high union rate and a good functional outcome.