Hans J. Kreder

Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: A RANDOMISED, CONTROLLED TRIAL

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups. During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised.

Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong?

A worldwide epidemic of hip fractures has been predicted. Time trends in BMD testing, bone‐sparing medications and hip and wrist fractures in the province of Ontario, Canada, were examined. From 1996 to 2001, BMD testing and use of bone‐sparing medications increased each year, whereas despite the aging of the population, wrist and hip fracture rates decreased.

Relationship between the Volume of Total Hip Replacements Performed by Providers and the Rates of Postoperative Complications in the State of Washington

Since the late 1970s, an empirical relationship between the volume of procedures performed by a provider (a hospital or surgeon) and the outcome has been documented for various operations. The present study examines the relationship between the volume of hip replacements performed by surgeons and hospitals and the postoperative rate of complications. A statewide hospital discharge registry was used to identify patients who had had an elective hip replacement between 1988 and 1991. Patients who had had a revision procedure, who had been referred on an emergency basis, or who had had a diagnosis of a fracture or a malignant tumor on admission were excluded. There were 7936 eligible patients who had had 8774 hip replacements. The average annual number of all hip replacements performed from 1987 through 1991 was subsequently determined for each hospital and surgeon who had cared for at least one patient in the study cohort. The rate of operative complications was modeled as a function of the volume of procedures performed by the surgeon or hospital (the surgeon or hospital volume), with adjustment for the age of the patient, gender, co-morbidity, and operative diagnosis. We noted significant differences in the case mix of low-volume providers compared with that of high-volume providers (p < 0.01). In general, surgeons and hospitals with a volume below the fortieth percentile managed patients who had a more adverse risk profile in terms of age, co-morbidity, and diagnosis. Even after adjustment for the case mix, there was a significant relationship between surgeons who averaged fewer than two hip replacements annually (low-volume surgeons) and a worse outcome (p < 0.05). Patients managed by these low-volume surgeons tended to have higher mortality rates, more infections, higher rates of revision operations, and more serious complications during the index hospitalization. The duration of hospitalization was inversely related to surgeon volume and directly associated with hospital volume. Hospital charges were inversely related to hospital volume, even after adjustment for patient-related factors as well as the duration of hospitalization, the year of the operation, and the destination after discharge (p < 0.05). More detailed information is required to investigate the reason for these observed variations in the rates of complications. If future studies confirm an association between low-volume providers and an adverse outcome, performance of some types of elective total hip replacements at regional centers should be considered.

X-ray film measurements for healed distal radius fractures

In order to understand the effect of malunion on functional outcome, it is essential that deformity be measured in a consistent manner. A standardized method of measuring eight anatomic parameters at the distal radius was developed. By this method, six x-ray films of healed distal radius fractures were subsequently measured by 16 raters. Rater agreement was quantified by using the intraclass correlation coefficient. Tolerance limits were developed in order to estimate the expected margin of error for each parameter. Parameters measured with high rater agreement include ulnar variance, palmar tilt, and radial shift; however, even experienced clinicians did not readily agree on the size of step and gap deformity. Using the method of tolerance limits, one would expect that two randomly chosen clinicians measuring step and gap deformity on a random x-ray film will differ by more than 3 mm at least 10% of the time. Similarly, repeat step or gap measurements by the same observer are expected to differ by more than 2 mm at least 10% of the time. In view of our inability to measure deformity more accurately, the concept of a specific relationship between a given degree of deformity and outcome must be questioned. Prospective research is needed in order to improve our understanding of the precise relationship between malunion and functional outcome.

Should Calcaneal Fractures Be Treated Surgically?: A Metaanalysis

A MEDLINE search from 1980 through 1996 revealed 1845 articles dealing with calcaneal fractures. Six of these articles that compared operative versus nonoperative treatment for displaced calcaneal fractures met the minimum criteria for inclusion in a metaanalysis. A statistical summary of information across the six articles revealed a trend for surgically treated patients to be more likely to return to the same type of work as compared with nonoperatively treated individuals. There also was a trend for nonoperatively treated patients to have a higher risk of experiencing severe foot pain than did operatively treated patients. Unfortunately, none of the other outcomes could be summarized formally across studies using statistical techniques because of variability in reporting across studies. Although the tendency was always for operatively treated patients to have better outcomes (reaching statistical significance in some of the articles), the strength of evidence to recommend operative treatment for displaced intraarticular calcaneal fractures remains weak. A large prospective randomized controlled trial should be able to answer this question.

Comparison of Early and Delayed Fixation of Subcapital Hip Fractures in Patients Sixty Years of Age or Less

Background: Subcapital hip fractures in younger patients are generally treated with internal fixation rather than with primary hemiarthroplasty, which is generally reserved for older, low-demand patients. Avascular necrosis can occur following this injury because of disruption of the femoral head blood supply. Some believe that emergent fracture reduction is necessary to minimize the risk of avascular necrosis. The purposes of this study were (1) to investigate the functional outcomes of subcapital hip fractures in patients sixty years old or younger and (2) to compare the rates of avascular necrosis after early and delayed fracture fixation.Methods: This retrospective study included adults in whom a subcapital hip fracture had been treated with reduction and internal fixation when they were sixty years of age or less and who had been followed clinically for a minimum of two years. The patients were divided into two groups: those treated with early fixation (within twelve hours after the injury) and those treated with delayed fixation (more than twelve hours after the injury). Functional outcomes were assessed with use of the Short Form-36 and the Western Ontario and McMaster University (WOMAC) Osteoarthritis Index. The rates of avascular necrosis were compared between the two groups.Results: Thirty-eight patients (average age, 46.4 years) participated in the study. Twenty-nine patients had a displaced subcapital hip fracture. Fifteen patients underwent early fracture fixation, and the remainder underwent delayed fixation. No differences in the Short Form-36 (p = 0.68) or WOMAC (p = 0.69) scores were seen between the early and delayed fixation groups. Radiographic evidence of avascular necrosis developed in six patients treated with delayed fixation, one of whom had had an undisplaced fracture preoperatively, and in no patient treated with early fixation. The difference in the rates of avascular necrosis was significant (p = 0.03).Conclusions: Although delayed surgical treatment of subcapital hip fractures was associated with a higher rate of avascular necrosis, this complication did not significantly affect functional outcome. Longer follow-up is required to assess the effect of avascular necrosis on the development of arthritis and on long-term patient function. Although the results could be biased because patients were not randomly assigned to delayed or early fixation, the data suggest that urgent reduction and fracture fixation within twelve hours after a displaced subcapital hip fracture in high-demand patients may be associated with a reduced rate of radiographic signs of avascular necrosis.

Determinants of functional outcome after simple and complex acetabular fractures involving the posterior wall

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.

You're perfect for the procedure! Why don't you want it? Elderly arthritis patients' unwillingness to consider total joint arthroplasty surgery: a qualitative study.

Objective . To explore the process by which elderly persons make decisions about a surgical treatment, total joint arthroplasty (TJA). Methods . In-depth interviews with 17 elderly individuals identified as potential candidates for TJA who were unwilling to undergo the procedure. Results . For the majority of participants, decision making involved ongoing deliberation of the surgical option, often resulting in a deferral of the treatment decision. Three assumptions may constrain elderly persons from making a decision about surgery. First, some participants viewed osteoarthritis not as a disease but as a normal part of aging. Second, despite being candidates for TJA according to medical criteria, many participants believed candidacy required a level of pain and disability higher than their current level. Third, some participants believed that if they either required or would benefit from TJA, their physicians would advise surgery. Conclusion . These assumptions may limit the possibility for shared decision making. Clinical Implications . Emphasis should be directed toward thinking about ways in which discussions about TJA might be initiated (and by whom) and considering how patients’ views on and knowledge of osteoarthritis in general might be addressed.

Which Patients Are Most Likely to Benefit From Total Joint Arthroplasty

OBJECTIVE To evaluate patient predictors of good outcome following total joint arthroplasty (TJA). METHODS A population cohort with hip/knee arthritis (osteoarthritis [OA] or inflammatory arthritis) ages ≥55 years was recruited between 1996 and 1998 (baseline) and assessed annually for demographics, troublesome joints, health status, and overall hip/knee arthritis severity using the Western Ontario and McMaster Universities OA Index (WOMAC). Survey data were linked with administrative databases to identify primary TJAs. Good outcome was defined as an improvement in WOMAC summary score greater than or equal to the minimal important difference (MID; 0.5 SD of the mean change). Logistic regression and Akaikes information criterion were used to determine the optimal number of predictors and the best model of that size. Log Poisson regression was used to determine the relative risk (RR) for a good outcome. RESULTS Primary TJA was performed in 202 patients (mean age 71.0 years; 79.7% female; 82.7% with >1 troublesome hip/knee; 65.8% knee replacements). Mean improvement in WOMAC summary score was 10.2 points (SD 18.05; MID 9 points). Of these patients, 53.5% experienced a good outcome. Four predictors were optimal. The best 4-variable model included pre-TJA WOMAC, comorbidity, number of troublesome hips/knees, and arthritis type (C statistic 0.80). The probability of a good outcome was greater with worse (higher) pre-TJA WOMAC summary scores (adjusted RR 1.32 per 10-point increase; P < 0.0001), fewer troublesome hips/knees (adjusted RR 0.82 per joint; P = 0.002), OA (adjusted RR for rheumatoid arthritis versus OA 0.33; P = 0.009), and fewer comorbidities (adjusted RR per condition 0.88; P = 0.01). CONCLUSION In an OA cohort with a high prevalence of multiple troublesome joints and comorbidity, only half achieved a good TJA outcome, defined as improved pain and disability. A more comprehensive assessment of the benefits and risks of TJA is warranted.

Unstable pertrochanteric femoral fractures.

Background: Fractures in the trochanteric region of the femur are classified as AO/OTA 31-A, as they are extracapsular1 (Fig. 1). This report analyzes the relatively rare 31-A3 fracture, which has also been referred to as an “intertrochanteric femur fracture with subtrochan-teric extension,” “reverse obliquity intertrochanteric femur fracture,” “unstable intertrochanteric femur fracture,” or a “subtrochanteric femur fracture.” The A3 fracture is characterized by having a fracture line exiting the lateral femoral cortex distal to the vastus ridge. Possible fixation constructs include compression hip screws, intramedullary hip screws, trochanteric intramedullary nails, cephalomedullary antegrade intramedullary nails, and 95° plates. Most reports investigating 31-A fractures do not describe the 31-A3 fracture. For this analysis, only reports clearly indicating that the fracture treated was a 31-A3 were included. It should be understood that this approach therefore excludes reports on generic “subtrochanteric fractures” or “intertrochanteric fractures,” some of which may have been 31-A3 fractures. Objective: To determine the effect of fixation technique for the AO/OTA 31-A3 fracture on rates of union, infection, risk of reopera-tion, and functional outcomes.