Gustaf Neander

Total hip replacement versus open reduction and internal fixation of displaced femoral neck fractures: a randomized long-term follow-up study.

BACKGROUND Clinical trials with short and intermediate-term follow-up have demonstrated superior results for total hip replacement as compared with internal fixation with regard to hip function and the need for secondary surgery in elderly patients with a displaced intracapsular femoral neck fracture. The aim of the present study was to compare the results of total hip replacement with those of internal fixation over a long-term follow-up period of seventeen years. METHODS We enrolled 100 patients who had sustained a femoral neck fracture in a single-center, randomized controlled trial;all patients had had a healthy hip before the injury. The study group included seventy-nine women and twenty-one men with a mean age of seventy-eight years (range, sixty-five to ninety years). The subjects were randomly assigned to either total hip replacement (the arthroplasty group) (n = 43) or internal fixation (the control group) (n = 57). The primary end point was hip function, evaluated with use of the Harris hip score. Secondary end points included mortality, reoperations, gait speed, and activities of daily life. Follow-up evaluations were performed at three months and at one, two, four, eleven, and seventeen years. RESULTS The Harris hip score was higher in the total hip arthroplasty group, with a mean difference of 14.7 points (95%confidence interval, 9.2 to 20.1 points; p < 0.001 [analysis of covariance]) during the study period. We found no difference in mortality between the two groups. Four patients (9%) in the total hip replacement group and twenty-two patients (39%) in the internal fixation group had undergone a major reoperation (relative risk, 0.24; 95% confidence interval, 0.09 to 0.64).The overall reoperation rate was 23% (ten of forty-three) in the total hip replacement group and 53% (thirty of fifty-seven) in the internal fixation group (relative risk, 0.44; 95% confidence interval, 0.24 to 0.80). The results related to gait speed and activities of daily living favored the arthroplasty group during the first year. CONCLUSIONS Over a period of seventeen years in a group of healthy, elderly patients with a displaced femoral neck fracture, total hip replacement provided better hip function and significantly fewer reoperations compared with internal fixation without increasing mortality. LEVEL OF EVIDENCE Therapeutic Level I.

Effects of desmopressin on blood loss in hip arthroplasty. Controlled study in 50 patients.

50 patients undergoing elective total hip replacement under epidural anesthesia and dextran infusion were given two doses of the vasopressin analogue desmopressin 0.3 micrograms/kg BW or placebo in a double-blinded randomized prospective study. Intraoperative blood loss and drainage loss did not differ significantly between groups, but desmopressin reduced the mean total blood loss (calculated from hemoglobin decrease and blood transfusions) by 310 mL (P less than 0.05).

Blood loss in total hip replacement

SummaryTwo hundred and twelve total hip replacements performed in one clinic over 1 year were reviewed. The mean operative time was 89 min and mean total blood loss 1090 ml. Homologous blood was administered to 74% of the patients. Blood loss was dependent on sex, body weight and height, but these correlations were eliminated when blood loss was related to estimated blood volume. There was no correlation to age. There was a positive correlation between operative time and intraoperative blood loss, but not between any of these factors and postoperative blood loss. Operative time varied significantly between surgeons, but there was no correlation between surgeons experience and operative time or blood loss. Despite a mean of only 12 total hip replacements per surgeon, both operative time and blood loss were small compared to what was found in other studies. The use of a posterior approach is believed to contribute to a shorter operative time as well as to moderate blood loss. Intraoperative blood loss was less under epidural than under general anaesthesia, but in contrast to others we found higher postoperative blood loss after epidural anaesthesia.

Bone and muscle mass after femoral neck fracture

The cortical bone mineral density (BMD), bone volume, bone mass and muscle volume of the thigh, and the BMD of the distal femur and proximal tibia were measured quantified by quantitative computed tomography (QCT) after an operation for a displaced femoral neck fracture. Twenty patients were randomized to osteosynthesis or total hip arthroplasty (THA). Both legs were scanned after 18 months, and the operated side was compared with the healthy side. Clinical assessment was performed with a Harris hip score. A reference group of 9 patients, who had undergone THA because of arthrosis, was chosen. In the fracture patients, we found a 9% decrease in bone mass and muscle volume of the middle femur. The BMD of the distal femur and proximal tibia showed a more marked osteopenia. There was no difference in these parameters between the two groups. In the reference group of operated arthrosis patients, we did not find any differences between sides postoperatively. After the operation, the fracture patients had a lower Harris score than the arthrosis patients, and this was most pronounced among those who had undergone osteosynthesis. The finding of a marked osteopenia after a femoral neck fracture, irrespective of treatment, but no bone loss after THA because of arthrosis, implies that patients with a femoral neck fracture are more sensitive to osteopenia, and that the bone loss is not proportional to the operative trauma. caused by the disuse and the posttraumatic effect on the bone caused by the operation. Also, the magnitude of the operative trauma may play a role in the development of the osteopenia. Thus, a displaced femoral neck fracture, treated with osteosynthesis or total hip arthroplasty (THA), offers a possibility to distinguish between the osteopenia caused by the fracture and the role of the operation, since the degree of the operative trauma is different. The aim of this study was to investigate whether or not the bone loss after a displaced femoral neck fracture depends on the mode of treatment.

Naproxen and paracetamol compared with naproxen only in coxarthrosis: Increased effect of the combination in 18 patients

In a double-blind study of 18 patients with coxarthrosis the effect of 3 naproxen doses (0.5, 1.0, and 1.5 g daily) and 2 naproxen doses combined with paracetamol (0.5 g + 4 g daily and 1.0 g + 4 g daily) was investigated. Plasma levels of naproxen and paracetamol were measured (HPLC), and clinical assessment of pain, joint movement, activity of daily life and side-effects were performed at the end of the 5 treatment periods. A relationship was found between the 3 naproxen doses, naproxen plasma levels, pain at rest, and pain during movement. The combined treatment was more effective than treatment with the same naproxen dose alone. The effect of naproxen (0.5 g daily) combined with paracetamol (4 g daily) did not differ from that obtained during treatment with higher naproxen doses only. Furthermore, the effect of the highest naproxen dose was not better than the effect of the lower naproxen dose (1.0 g daily) combined with paracetamol. The main finding was that treatment with naproxen and paracetamol is more effective than treatment with higher naproxen doses alone.

Decrease in bone mineral density and muscle mass after femoral neck fracture: A quantitative computed tomography study in 25 patients

We performed a prospective, longitudinal, quantitative computed tomography (QCT) study of bone mineral density (BMD), cortical bone volume, bone mass and muscle volume in 25 patients who were operated on with osteosynthesis because of a displaced femoral neck fracture. Both legs were scanned within 3 days after the fracture, and 3 and 6 months after the operation. The measurements were performed by a computer tomograph equipped for bone mineral densitometry. We found some side differences among the patients at the time of fracture, but none of the differences was statistically significant. After 6 months, we found reductions in BMD in the distal femur and proximal tibia on the fractured side of 11% and 19%, respectively, as well as a reduction in BMD of 7% in the proximal tibia on the uninjured side. We found no changes in cortical bone mass, either on the fractured femur or on the uninjured femur. The muscles of the thigh showed a loss of 9% on the fractured side, but a gain of 12% on the uninjured side. The findings of a bone loss in the distal femur and proximal tibia of the fractured leg and in the proximal tibia of the healthy leg, but no cortical bone loss in the middle femur on any side 6 months after the fracture, indicate that the cancellous bone is more sensitive to osteopenia. Moreover, this bone loss is interpreted as mainly a posttraumatic effect, since we also found a decrease in bone mineral on the uninjured side, despite a gain in muscle volume on that side, an overuse which was not sufficient to counteract the posttraumatic effect on the bone of the uninjured side.

Risk factors for osteoporosis are common in young and middle-aged patients with femoral neck fractures regardless of trauma mechanism

Background and purpose There have been few prospective studies examining young and middle-aged patients with hip fracture. We therefore investigated background data, risk factors, and the trauma mechanism in young and middle-aged patients with femoral neck fracture. Patients and methods 185 patients, 27 young (20–49 years old) and 158 middle-aged (50–69 years old) were prospectively included in a multicenter study lasting 3 years. Background data and risk factors for osteoporosis and fracture were obtained, and the type of injury was classified as low-energy trauma, high-energy trauma, or sports injury. Results In the young age group, the fracture occurred because of low-energy trauma in two-fifths of patients and because of sport injury in two-fifths of patients. The rest occurred because of high-energy trauma. The corresponding proportions for the middle-aged group were four-fifths, one tenth, and one tenth (p < 0.001). There was a higher proportion of men (19/27) in the young group than in the middle-aged group (69/158) (p = 0.001). One fifth of the young patients were smokers as compared to two-fifths in the middle-age group (p = 0.04). One quarter of the patients reported high-volume alcohol drinking, with no difference between the two groups. Furthermore, three-quarters of the young patients and four-fifths of the middle-aged patients had one or more risk factors for osteoporosis and fracture. Interpretation A minority of patients in each age group had high-energy trauma as the cause of their femoral neck fracture. Lifestyle factors and other non-trauma-related risk factors appear to have been important contributors to the occurrence of femoral neck fracture in both age groups.

Ureaplasma urealyticum Infection in Total Hip Arthroplasty Leading to Revision

We describe an infection with Ureaplasma urealyticum causing rapid loosening of a cemented total hip arthroplasty. When reviewing the literature we found that no such case has been reported previously. Taking intraoperative cultures for U urealyticum during revision surgery is not a standard procedure. In cases with rapid, presumed aseptic, loosening of a total hip arthroplasty, an infection with U urealyticum should be considered.

Low bone mineral density and fat-free mass in younger patients with a femoral neck fracture

Reduced bone mineral density (BMD) together with muscle wasting and dysfunction, that is sarcopenia, emerges as a risk factor for hip fracture. The aim of this study was to examine body composition and BMD and their relationship with trauma mechanisms in young and middle‐aged patients with femoral neck fracture.