Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes. Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries.Aims
Methods
There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion.Aims
Methods
We prospectively assessed the diagnostic accuracy
of the gravity stress test and clinical findings to evaluate the stability
of the ankle mortise in patients with supination–external rotation-type
fractures of the lateral malleolus without widening of the medial
clear space. The cohort included 79 patients with a mean age of
44 years (16 to 82). Two surgeons assessed medial tenderness, swelling
and ecchymosis and performed the external rotation (ER) stress test
(a reference standard). A diagnostic radiographer performed the
gravity stress test. For the gravity stress test, the positive likelihood ratio (LR)
was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and
the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate
change from the pre-test probability. Medial tenderness, both alone
and in combination with swelling and/or ecchymosis, indicated a
small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47),
whereas swelling and ecchymosis indicated only minimal changes (positive
LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). . In conclusion, when gravity stress test results are in agreement
with clinical findings, the result is likely to predict stability
of the ankle mortise with an accuracy equivalent to ER stress test
results. When
We treated 17 knees in 15 patients with severe ligament derangement and dislocation by open repair and reconstruction. We assessed the competence of all structures thought to be important for stability by
The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated. The study included 34 patients who were diagnosed with CFES following trauma between 2012 and 2018. The clinical diagnosis was confirmed and the severity graded by MRI. We investigated the rate of mortality, the time and extent of neurological recovery, the time between the injury and the onset of symptoms, the clinical severity of the condition, and the MRI grade. All patients were male with a mean age of 29.7 years (18 to 70). The mean follow-up was 4.15 years (2 to 8), with neurological recovery being assessed by the Glasgow Outcome Scale and the Mini-Mental State Examination.Aims
Methods
Objectives. Nonunion is one of the most troublesome complications to treat
in orthopaedics. Former authors believed that atrophic nonunion
occurred as a result of lack of mesenchymal stem cells (MSCs). We
evaluated the number and viability of MSCs in site of atrophic nonunion compared
with those in iliac crest. Methods. We enrolled five patients with neglected atrophic nonunions of
long bones confirmed by
It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management. Patient data from a randomized controlled trial were used to compare acute plate fixation with nonoperative management of united fractures. Return of shoulder function was based on the age- and sex-matched Disabilities of the Arm, Shoulder and Hand (DASH) scores for the cohort. Independent predictors of an early recovery of normal shoulder function were investigated using a separate prospective series of consecutive nonoperative displaced mid-shaft clavicular fractures recruited over a two-year period (aged ≥ 16 years). Patient demographics and functional recovery were assessed over the six months post-injury using a standardized protocol.Aims
Methods
Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA). We conducted a retrospective, registry-based study of 80 patients aged 60 years and older with acetabular fractures treated surgically at The Alfred and Royal Melbourne Hospital. We reviewed charts and radiological investigations and performed patient interviews/examinations and functional outcome scoring. Data were provided by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Survival analysis was used to describe conversion to THA in the group of patients who initially underwent open reduction and internal fixation (ORIF). Multivariate regression analyses were performed to identify factors associated with conversion to THA.Aims
Methods
We have treated 94 patients with chronic instability of the lateral side of the ankle by reconstruction of the ligaments with local periosteal tissue. We reviewed 90 cases after a mean follow-up of 2.8 years (2 to 9) using a questionnaire,
The imaging techniques available to aid the diagnosis of ruptures of tendo Achillis, the rotator cuff and the tendon of tibialis posterior in rheumatoid patients are well described. However, ruptures of tendon or muscle at other sites are uncommon and may be overlooked. Diagnosis is often made by localised tenderness, swelling and a lack of active movement associated with a palpable defect.
Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP. This is a retrospective and observational study containing data from nine patients with a mean age of 14.1 years (9 to 25; three female, six male) with OP who were treated in our hospital between April 2008 and October 2018 with 20 surgical procedures due to 17 different fractures. Patient data included age, sex, operating time, length of stay, genetic type of the disease, previous surgery, fractures, complications, and comorbidity.Aims
Methods
The aim of this study was to evaluate near-infrared spectroscopy
(NIRS) as a continuous, non-invasive monitor for acute compartment
syndrome (ACS). NIRS sensors were placed on 86 patients with, and 23 without
(controls), severe leg injury. NIRS values were recorded for up
to 48 hours. Longitudinal data were analyzed using summary and graphical
methods, bivariate comparisons, and multivariable multilevel modelling.Aims
Patients and Methods
We aimed to identify the pattern of nerve injury associated with
paediatric supracondylar fractures of the humerus. Over a 17 year period, between 1996 and 2012, 166 children were
referred to our specialist peripheral nerve injury unit. From examination
of the medical records and radiographs were recorded the nature
of the fracture, associated vascular and neurological injury, treatment
provided and clinical course.Aims
Patients and Methods
The best method of managing a fracture of the
distal humerus in a frail low-demand patient with osteoporotic bone remains
controversial. Total elbow arthroplasty (TEA) has been recommended
for patients in whom open reduction and internal fixation (ORIF)
is not possible. Conservative methods of treatment, including the
‘bag of bones’ technique (acceptance of displacement of the bony
fragments and early mobilisation), are now rarely considered as
they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93
years, 72% women) with a fracture of the distal humerus who had
been treated conservatively at our hospital between March 2008 and
December 2013, and assessed their short- and medium-term functional
outcome. In the short-term, the mean Broberg and Morrey score improved
from 42 points (poor; 23 to 80) at six weeks after injury to 67
points (fair; 40 to 88) by three months. In the medium-term, surviving patients (n = 20) had a mean Oxford
elbow score of 30 points (7 to 48) at four years and a mean Disabilities
of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95%
reported a functional range of elbow flexion. The cumulative rate
of fracture union at one year was 53%. The mortality at five years approached
40%. Conservative management of a fracture of the distal humerus in
a low-demand patient only gives a modest functional result, but
avoids the substantial surgical risks associated with primary ORIF
or TEA. Cite this article:
Our aim was to compare the one-year post-operative
outcomes following retention or removal of syndesmotic screws in
adult patients with a fracture of the ankle that was treated surgically.
A total of 51 patients (35 males, 16 females), with a mean age of
33.5 years (16 to 62), undergoing fibular osteosynthesis and syndesmotic
screw fixation, were randomly allocated to retention of the syndesmotic
screw or removal at three months post-operatively. The two groups
were comparable at baseline. One year post-operatively, there was no significant difference
in the mean Olerud–Molander ankle score (82.4 retention We conclude that removal of a syndesmotic screw produces no significant
functional, clinical or radiological benefit in adult patients who
are treated surgically for a fracture of the ankle. Cite this article:
We retrospectively reviewed 2989 consecutive
patients with a mean age of 81 (21 to 105) and a female to male
ratio of 5:2 who were admitted to our hip fracture unit between
July 2009 and February 2013. We compared weekday and weekend admission
and weekday and weekend surgery 30-day mortality rates for hip fractures
treated both surgically and conservatively. After adjusting for
confounders, weekend admission was independently and significantly
associated with a rise in 30-day mortality (odds ratio (OR) 1.4,
95% confidence interval (CI) 1.02 to 1.9; p = 0.039) for patients
undergoing hip fracture surgery. There was no increase in mortality
associated with weekend surgery (OR 1.2, 95% CI 0.8 to 1.7; p =
0.39). All hip fracture patients, whether managed surgically or
conservatively, were more likely to die as an inpatient when admitted
at the weekend (OR 1.4, 95% CI 1.02 to 1.80; p = 0.032), despite
our unit having a comparatively low overall inpatient mortality
(8.7%). Hip fracture patients admitted over the weekend appear to
have a greater risk of death despite having a consultant-led service. Cite this article:
Injuries to the limb are the most frequent cause
of permanent disability following combat wounds. We reviewed the medical
records of 450 soldiers to determine the type of upper limb nerve
injuries sustained, the rate of remaining motor and sensory deficits
at final follow-up, and the type of Army disability ratings granted.
Of 189 soldiers with an injury of the upper limb, 70 had nerve-related
trauma. There were 62 men and eight women with a mean age of 25
years (18 to 49). Disabilities due to nerve injuries were associated
with loss of function, neuropathic pain or both. The mean nerve-related
disability was 26% (0% to 70%), accounting for over one-half of
this cohort’s cumulative disability. Patients injured in an explosion
had higher disability ratings than those injured by gunshot. The
ulnar nerve was most commonly injured, but most disability was associated
with radial nerve trauma. In terms of the final outcome, at military
discharge 59 subjects (84%) experienced persistent weakness, 48
(69%) had a persistent sensory deficit and 17 (24%) experienced
chronic pain from scar-related or neuropathic pain. Nerve injury
was the cause of frequent and substantial disability in our cohort
of wounded soldiers. Cite this article:
The Essex-Lopresti injury (ELI) of the forearm
is a rare and serious condition which is often overlooked, leading
to a poor outcome. The purpose of this retrospective case study was to establish
whether early surgery can give good medium-term results. From a group of 295 patients with a fracture of the radial head,
12 patients were diagnosed with ELI on MRI which confirmed injury
to the interosseous membrane (IOM) and ligament (IOL). They were
treated by reduction and temporary Kirschner (K)-wire stabilisation
of the distal radioulnar joint (DRUJ). In addition, eight patients
had a radial head replacement, and two a radial head reconstruction. All patients were examined clinically and radiologically 59 months
(25 to 90) after surgery when the mean Mayo Modified Wrist Score
(MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores
(MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder
and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome. In case of a high index of suspicion for ELI in patients with
a radial head fracture, we recommend the following: confirmation
of IOM and IOL injury with an early MRI scan; early surgery with
reduction and temporary K-wire stabilisation of the DRUJ; preservation
of the radial head if at all possible or replacement if not, and
functional bracing in supination. This will increase the prospect
of a good result, and avoid the complications of a missed diagnosis
and the difficulties of late treatment. Cite this article:
Patients with transfemoral amputation (TFA) often
experience problems related to the use of socket-suspended prostheses.
The clinical development of osseointegrated percutaneous prostheses
for patients with a TFA started in 1990, based on the long-term
successful results of osseointegrated dental implants. Between1999 and 2007, 51 patients with 55 TFAs were consecutively
enrolled in a prospective, single-centre non-randomised study and
followed for two years. The indication for amputation was trauma
in 33 patients (65%) and tumour in 12 (24%). A two-stage surgical
procedure was used to introduce a percutaneous implant to which
an external amputation prosthesis was attached. The assessment of
outcome included the use of two self-report questionnaires, the
Questionnaire for Persons with a Transfemoral Amputation (Q-TFA)
and the Short-Form (SF)-36. The cumulative survival at two years’ follow-up was 92%. The
Q-TFA showed improved prosthetic use, mobility, global situation
and fewer problems (all p <
0.001). The physical function SF-36
scores were also improved (p <
0.001). Superficial infection
was the most frequent complication, occurring 41 times in 28 patients
(rate of infection 54.9%). Most were treated effectively with oral
antibiotics. The implant was removed in four patients because of loosening
(three aseptic, one infection). Osseointegrated percutaneous implants constitute a novel form
of treatment for patients with TFA. The high cumulative survival
rate at two years (92%) combined with enhanced prosthetic use and
mobility, fewer problems and improved quality of life, supports
the ‘revolutionary change’ that patients with TFA have reported
following treatment with osseointegrated percutaneous prostheses. Cite this article:
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:
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.
In an interdisciplinary project involving electronic
engineers and clinicians, a telemetric system was developed to measure
the bending load in a titanium internal femoral fixator. As this
was a new device, the main question posed was: what clinically relevant
information could be drawn from its application? As a first clinical
investigation, 27 patients (24 men, three women) with a mean age
of 38.4 years (19 to 66) with femoral nonunions were treated using the
system. The mean duration of the nonunion was 15.4 months (5 to
69). The elasticity of the plate-callus system was measured telemetrically
until union. Conventional radiographs and a CT scan at 12 weeks
were performed routinely, and healing was staged according to the
CT scans. All nonunions healed at a mean of 21.5 weeks (13 to 37).
Well before any radiological signs of healing could be detected,
a substantial decrease in elasticity was recorded. The relative
elasticity decreased to 50% at a mean of 7.8 weeks (3.5 to 13) and
to 10% at a mean of 19.3 weeks (4.5 to 37). At 12 weeks the mean
relative elasticity was 28.1% (0% to 56%). The relative elasticity
was significantly different between the different healing stages
as determined by the CT scans. Incorporating load measuring electronics into implants is a promising
option for the assessment of bone healing. Future application might
lead to a reduction in the need for exposure to ionising radiation
to monitor fracture healing.
There have been many advances in the resuscitation
and early management of patients with severe injuries during the
last decade. These have come about as a result of the reorganisation
of civilian trauma services in countries such as Germany, Australia
and the United States, where the development of trauma systems has
allowed a concentration of expertise and research. The continuing
conflicts in the Middle East have also generated a significant increase
in expertise in the management of severe injuries, and soldiers
now survive injuries that would have been fatal in previous wars.
This military experience is being translated into civilian practice. The aim of this paper is to give orthopaedic surgeons a practical,
evidence-based guide to the current management of patients with
severe, multiple injuries. It must be emphasised that this depends
upon the expertise, experience and facilities available within the
local health-care system, and that the proposed guidelines will
inevitably have to be adapted to suit the local resources.
There have been recent reports linking alendronate and a specific pattern of subtrochanteric insufficiency fracture. We performed a retrospective review of all subtrochanteric fractures admitted to our institution between 2001 and 2007. There were 20 patients who met the inclusion criteria, 12 of whom were on long-term alendronate. Alendronate-associated fractures tend to be bilateral (Fisher’s exact test, p = 0.018), have unique radiological features (p <
0.0005), be associated radiologically with a pre-existing ellipsoid thickening of the lateral femoral cortex and are likely to be preceded by prodromal pain. Biomechanical investigations did not suggest overt metabolic bone disease. Only one patient on alendronate had osteoporosis prior to the start of therapy. We used these findings to develop a management protocol to optimise fracture healing. We also advocate careful surveillance in individuals at-risk, and present our experience with screening and prophylactic fixation in selected patients.
We have carried out a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. We describe the heterogeneity of these fractures, their association with multiple injuries and the need for multilevel stability with the least compromise of the biology of the fracture segments. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36). The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients. Two had nonunion at the distal level, one a wire-related infection which required further surgery and another shortening of 15 mm with 8° of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm. This may be explained by the presence of multiple injuries affecting the overall score.
We have investigated how medical postponement, the time to surgery and the correction of medical abnormalities, according to McLaughlin criteria, before operation affected peri-operative mortality after fracture of the hip. From February to December 2007, in addition to core data, the Scottish Hip Fracture Audit collected information relating to surgical delay. Data were available for 4284 patients which allowed 30-day survival analysis to be performed. Multivariable logistic regression models were used to control for differences in case-mix. Patients with major clinical abnormalities were more likely to have a postponement and had a lower unadjusted 30-day survival. The time to operation and postponement were not associated with higher mortality after adjustment for case-mix. Correction of major clinical abnormalities before surgery improved the adjusted survival, but this improvement was not significant (p = 0.10). Postponement without correction of a medical abnormality before surgery was associated with a significantly lower (p = 0.006) 30-day adjusted survival. The possible benefits of postponement need to be weighed against prolonged discomfort for the patient and the possibility of the development of other complications.
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.
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 avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports. Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.
A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3° ( We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome.
The incidence of deep-vein thrombosis and the need for thromboprophylaxis following isolated trauma below the knee is uncertain. We have investigated this with a prospective randomised double-blind controlled trial using low molecular weight heparin with saline injection as placebo in patients aged between 18 and 75 years who had sustained an isolated fracture below the knee which required operative fixation. All patients had surgery within 48 hours of injury and were randomised to receive either the placebo or low molecular weight heparin for 14 days, after which they underwent bilateral lower limb venography, interpreted by three independent radiologists. Further follow-up was undertaken at two, six, eight and 12 weeks. A total of 238 patients fulfilled all the inclusion criteria, with 127 in the low molecular weight heparin group and 111 in the placebo group, all of whom underwent bilateral venography. There was no statistically significant difference in the incidence of deep-vein thrombosis between those patients treated with low molecular weight heparin or the placebo (p = 0.22). The number of deep-vein thromboses in the two groups was 11 (8.7%) and 14 (12.6%), respectively. Age and the type of fracture were significantly associated with the rate of deep-vein thrombosis (p = 0.001 and p = 0.009, respectively) but gender, comorbidities and the body mass index were not. The overall incidence of deep-vein thrombosis in this series was 11%. There was no clinical or statistical significant reduction in the incidence of deep-vein thrombosis with the use of thromboprophylaxis. However, we accept that owing to a cessation of funding, recruitment to this trial had to be ended prior to establishing the necessary sample size. Our results cannot, therefore, categorically exclude the possibility that low molecular weight heparin treatment could be beneficial. We recommend a further multicentre trial be undertaken to resolve this matter.
Fracture-dislocations of the tarsometatarsal (Lisfranc) joints are frequently overlooked or misdiagnosed at initial presentation. This is a comparative cohort study over a period of five years comparing primary open reduction and internal fixation in 22 patients (23 feet) with secondary corrective arthrodesis in 22 patients (22 feet) who presented with painful malunion at a mean of 22 months (1.5 to 45) after injury. In the first group primary treatment by open reduction and internal fixation for eight weeks with Kirschner-wires or screws was undertaken, in the second group treatment was by secondary corrective arthrodesis. There was one deep infection in the first group. In the delayed group there was one complete and one partial nonunion. In each group 20 patients were available for follow-up at a mean of 36 months (24 to 89) after operation. The mean American Orthopaedic Foot and Ankle Society midfoot score was 81.4 (62 to 100) after primary treatment and 71.8 (35 to 88) after corrective arthrodesis (t-test; p = 0.031). We conclude that primary treatment by open reduction and internal fixation of tarsometatarsal fracture-dislocations leads to improved functional results, earlier return to work and greater patient satisfaction than secondary corrective arthrodesis, which remains a useful salvage procedure providing significant relief of pain and improvement in function.
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.
The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery. Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.
The purpose of this study was to describe the anatomical distribution and incidence of fatigue injuries of the femur in physically-active young adults, based upon MRI studies. During a period of 70 months, 1857 patients with exercise-induced pain in the femur underwent MRI of the pelvis, hips, femora, and/or knees. Of these, 170 patients had a total of 185 fatigue injuries, giving an incidence of 199 per 100 000 person-years. Bilateral injuries occurred in 9% of patients. The three most common sites affected were the femoral neck (50%), the condylar area (24%) and the proximal shaft (18%). A fatigue reaction was seen in 57%, and a fracture line in 22%. There was a statistical correlation between the severity of the fatigue injury and the duration of pain (p = 0.001). The location of the pain was normally at the site of the fatigue injury. Fatigue injuries of the femur appear to be relatively common in physically-active patients.
Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome.
There is a high risk of venous thromboembolism when patients are immobilised following trauma. The combination of low-molecular-weight heparin (LMWH) with graduated compression stockings is frequently used in orthopaedic surgery to try and prevent this, but a relatively high incidence of thromboembolic events remains. Mechanical devices which perform continuous passive motion imitate contractions and increase the volume and velocity of venous flow. In this study 227 trauma patients were randomised to receive either treatment with the Arthroflow device and LMWH or only with the latter. The Arthroflow device passively extends and plantarflexes the feet. Patients were assessed initially by venous-occlusion plethysmography, compression ultrasonography and continuous wave Doppler, which were repeated weekly without knowledge of the category of randomisation. Those who showed evidence of deep-vein thrombosis underwent venography for confirmation. The incidence of deep-vein thrombosis was 25% in the LMWH group compared with 3.6% in those who had additional treatment with the Arthroflow device (p <
0.001). There were no substantial complications or problems of non-compliance with the Arthroflow device. Logistic regression analysis of the risk factors of deep-vein thrombosis showed high odds ratios for operation (4.1), immobilisation (4.3), older than 40 years of age (2.8) and obesity (2.2).