Antti Alho

Gamma nail vs compression screw for trochanteric femoral fractures: 15 reoperations in a prospective, randomized study of 378 patients

A total of 378 trochanteric and subtrochanteric femoral fractures were randomized to treatment with Gamma nail (177) or Hip Compression Screw (HCS) (201). After a median follow-up time of 17 (10-27) months, 15 patients needed reoperations; 13 had been treated with Gamma nail and 2 with HCS. 10 patients, all treated with Gamma nail, were reoperated because of a femoral shaft fracture. 5 of these fractures occurred 8 (4-10) days postoperatively and were related to intraoperative complications. The other 5 shaft fractures occurred a median of 2 (1-3) months postoperatively after falls, and may be related to stress concentration at the tip of the solid nail. The lag screw cut out or penetrated the femoral head in 5 patients, 3 of them treated with Gamma nail and 2 with HCS.

Concurrent ipsilateral fractures of the hip and femoral shaft:A meta-analysis of 659 cases

659 cases of concurrent, ipsilateral fractures in the hip and femoral shaft reported in 59 studies were analyzed. The causes were a road traffic accident in 78% and other types of high-energy traumas in 13% of the patients. This injury combination was rare in children. The median age was 34 years. 78% of the patients were men. One-third had multiple injuries, one-half had injuries of the ipsilateral knee and one-half had other lower limb injuries. The femoral neck fractures were most often basilar and the reported rate of avascular necrosis was 3%. The trochanteric fractures were intertrochanteric transverse, and seldom comminuted. The important factors in reducing morbidity were an early diagnosis of all injuries and efficient treatment of the shaft fractures. Locked intramedullary nails yielded results which were superior to combinations of plates or unlocked nails and separate hip screws. Reconstruction nails (cephalomedullary nails) gave results equal to those of customary locked nails and separate hip screws. The rate of healing of the hip fracture was over 99%, the treatment of the shaft fracture being of main importance for the outcome.

Effect of Instability on Experimental Fracture Healing

Bilateral tibial osteotomy with fracturing of the fibula was performed on ten Wistar rats weighing 300--350 g. Intramedullary nailing was performed with 1.4 mm nails after reaming. On the left side solid stainless rods were used, while on the right side the nails had a middle part made of titanium-nickel wire covered with polyvinylchloride (PVC), giving the nail a high degree of flexibility. After 8 weeks, nine of the ten flexible nails showed fracture of the central wire. The continuity was, however, maintained by the PVC tube. The bones with flexible nailing always showed hypertrophic callus while there was only scanty callus on the side with rigid nailing. Strength, deformation at fracture and stiffness were measured in a three-point bending test after removal of the solid nails and the fibulae. The strength of the tibiae was greatest on the side with flexible nailing, as was the deformation at fracture. The mean stiffness was higher in the bones with rigid nails, but the difference here was not statistically discernible.

Management of Fractured Scaphoid Bone: A Prospective Study of 100 Fractures

One hundred fractured carpal scaphoids were immobilised alternatively in above-elbow and below-elbow casts. Preventing the pronation and supination of the forearm did not reduce the immobilisation time, which, with either type of cast, averaged 7 weeks, after exclusion of the fractures with delayed union. These eight fractures, which did not unite in 3 months, were operated on using a lag screw fixation, whereafter consolidation was achieved.

Primary repair in posterior cruciate ligament injuries

A retrospective study of 32 consecutive patients with acute injury of the posterior cruciate ligament (PCL) treated by primary repair is presented. Only six patients had isolated injuries of the PCL, five of these as avulsion of a bone fragment from the tibia. The remaining 26 patients sustained combined ligament injuries, including 18 total ACL tears. All ruptured ligaments were repaired. At follow-up after 4 (1-7) years, function in 26 patients was excellent-good and in six fair-poor. Moderate or severe posterior instability was found in seven patients by clinical examination but their function was as good as in those with stable knees. Inferior functional results, however, were more often related to rotatory instability. Primary repair of PCL-injuries, including all associated ligament injuries, is recommended.

Internally fixed femoral neck fractures. Early prediction of failure in 203 elderly patients with displaced fractures.

After internal fixation of a femoral neck fracture, 3 months is the critical time for planning rehabilitation of the patient. Most failures in the elderly occur within this time. In a series of 165 patients, we followed 127 women and 38 men with a median age of 81 (63-97) years from an examination at 3 months to reoperation or survival of the hip. 36 patients had radiographic signs of disturbed healing at the 3-month follow-up--change in fracture position by 10 mm, change in screw position by 5%, backing of the screws by 20 mm, or perforation of the femoral head by the screw. These signs had a high association with local complications and need for a later reoperation. High age and male sex increased this association. Signs of impaired healing made nonunion likely, but did not predict late segmental collapse of the femoral head. Patients with signs of disturbed healing and those closest to them should be informed about the value of early check-ups in case of pain and impaired function.

INTERNAL FIXATION VERSUS ENDOPROSTHESIS IN THE TREATMENT OF FEMORAL NECK FRACTURES IN THE ELDERLY A Prospective Analysis of the Comparative Costs and the Consumption of Hospital Resources

The consumption of hospital resources and the costs involved in treating femoral neck fractures in the elderly were studied and a comparison was made between internal fixation (von Bahr screws) and primary prosthetic replacement (Christiansens endoprosthesis). The 1-year results of screw fixation were excellent or good in 55% of the patients, fair in 17% and poor in 28%, compared with 79% excellent or good results, 13% fair and 8% poor results in the prosthetic group. As regards the initial stay in hospital, prosthetic replacement was found to be associated with 2.4 times higher costs. This difference was reduced, however, by a more expensive follow-up and more frequent readmissions and reoperations in the internal fixation group. Considering the total costs, prosthetic replacement was found to be 1.6 times more expensive than internal fixation.

Immobilization of operated ankle fractures

Forty-three patients with stable internal fixation of fresh ankle fractures were treated at random with a plaster cast for 6 weeks without weight bearing or were only immobilized for 3 days, after which active movements were encouraged. The two groups were followed for a year. Only at 6 weeks were there significant differences between the groups.

Mechanical factors in loosening of Christiansen and Charnley arthroplasties

A series of 96 Christiansen and 23 Charnley hip arthroplasties, mainly for osteoarthrosis, were followed for an average of 40 (15-93) months. Radiolucent zones at the cement bone interface and resorption of the calcar were more frequent in the Christiansen than in the Charnley hips. Medial and axial migration, and cement fracture often occurred concurrently, with a total frequency of 27/96 in the Christiansen and 4/23 in the Charnley subseries. Wide radiolucent zones in the acetabular cement bone interface were more frequent in the Christiansen hips. Six acetabular protrusions were observed in the Christiansen hips against none in the Charnley hips. The average Harris hip scores were significantly higher for the Charnley than for the Christiansen hips. Reoperation for loosening was performed in two Charnley hips and 19 Christiansen hips.

The Risk of Acetabular Protrusion Following Prosthetic Replacement of the Femoral Head

A total of 24 patients treated with hemiarthroplasty showed a crude frequency of acetabular protrusion of 26 per cent. Two factors were associated with the development of protrusion: the length of the follow-up period and previous hip operation. The frequency of protrusion was estimated using logistic regression techniques based on information concerning the age of the patients, the length of the follow-up period and any previous hip operation. The frequency ranged from 4.8 per cent for a patient of 75 years or under, with a follow-up period of less than 12 months and no previous hip operation, to 61 per cent for patients of over 75 years, with a follow-up period exceeding 12 months, and a previous hip operation. Patients of over 75 years were 1.7 times more likely to develop protrusion than younger patients, patients previously operated on were 2.3 times more likely to develop protrusion than those not operated on previously, and patients with a follow-up time period exceeding 12 months were 7.9 times more likely to develop protrusion than patients with a shorter follow-up time.