J. Steen Jensen

Trochanteric Femoral Fractures Treated with McLaughlin Osteosynthesis

Of 317 patients with trochanteric femoral fractures, 305 were treated with McLaughlin osteosynthesis. The mortality rate was 14.5 per cent. The postoperative complication rate (35.6 per cent) was dominated by cardiopulmonary (10.6 per cent) and thromboembolic (10.6 per cent) events. Wound infection was found in 3.8 per cent and osteitis in 0.9 per cent. In all, 106 patients had stable fractures according to the Evans classification. Of these, four had to be re-operated due to penetration or a loose bolt. Two hundred and eleven patients (66.6 per cent) had unstable fractures. Follow-up of 169 patients showed two-thirds to have healed in unchanged position. Only 14.8 per cent of the 169 patients had significant fracture complications, particularly varus dislocation of more than 20 degrees (nine patients) and penetration of the nail (eight patients). A total of 10 patients (5.9 per cent) had to be re-operated because of varus dislocation, broken plate or development of pseudarthrosis after removal of the osteosynthesis material. McLaughlin osteosynthesis is concluded to be a suitable method for the treatment of trochanteric femoral fractures--also of the unstable type.

Unstable trochanteric fractures treated with the sliding screw-plate system. A biomechanical study of unstable trochanteric fractures. III.

Eighty unstable trochanteric fractures were treated with the sliding screw-plate system. Early weight-bearing was encouraged and mobilization was obtained within the first week in 47 per cent of the cases (37/78). Technical complications were encountered in 5 per cent of the patients (4/76) but none required re-operation. Telescoping of the screw occurred in 49 per cent (37/76). Through this secondary fracture impaction a stable load transmission system was established. Fracture union in the postoperative position was obtained in 49 per cent of the patients (37/76) and non-union did not occur.

A Long Term Follow-Up of Moore Arthroplasty in Femoral Neck Fractures

Moore arthroplasty was performed for medial femoral neck fractures in 169 patients. The mortality rate was 21.3 per cent within 3 months. The general postoperative complication rate (39.6 per cent) was dominated by cardiopulmonary (17.2 per cent) and thromboembolic (16.0 per cent) events. Of local complications, wound infection was found in 4.7 per cent and osteitis in 3.0 per cent of cases. A total of 60 patients were followed up with a mean observation time of 4.9 years. Of these, 8.3 per cent sustained femoral fractures during this period. The results classified according to the criteria of the American Academy of Orthopedic Surgeons showed 52 per cent excellent or good, 43 per cent fair and 5 per cent poor results. The roentgenological finding of settling or osteolysis along the prosthesis was significantly correlated to reduced hip mobility. Ossification in the prosthetic fenestres gave significantly diminished settling, and was correlated to better hip mobility and less pain. In our opinion, Moore arthroplasty has proved to be an acceptable method for the treatment of femoral neck fractures in elderly patients, as 73 per cent had an acceptable range of motion, 40 per cent managed walking distances of more than 500 m and 70 per cent had minimal or no pain. Although 25 per cent became nursing home patients, this reduction of vitality could be related to the hip arthroplasty in only two cases.

Costs of treatment of hip fractures. A calculation of the consumption of the resources of hospitals and rehabilitation institutions.

A series of 518 patients with hip fractures and a median age of 78 years was followed for 6 months. On admission to hospital the patients were assessed and were found to be evenly distributed among four social function groups according to their level of dependence on the social welfare system. At the 6 months follow-up the mortality rate was about 16 per cent, leaving 437 patients for a reassessment of social function. The average hospitalization time was 23 days; thus 17 per cent of all orthopaedic hospital beds in the area were occupied by patients with hip fractures. Patients staying the longest time in hospital were those waiting for discharge to a nursing home. The average stay in rehabilitation institutions was 71 days. The total rehabilitation course was longest for the most dependent patients. The risk of death or deterioration of social function among patients admitted from home was 48 per cent. In the case of social deterioration or technical failure following the fracture treatment the total rehabilitation course was considerably prolonged. The resources required for the treatment of hip fractures in a suburban area of 500,000 inhabitants were calculated to the 32 hospital beds, 43 rehabilitation beds and at least 21 nursing home beds.

Tibial shaft fractures: A comparison of conservative treatment and internal fixation with conventional plates or ao compression plates

Out of a series of 207 consecutive fractures of the tibial shaft, 102 were treated conservatively, 64 fractures were treated by AO compression plate osteosynthesis and 41 by internal fixation using Eggers or Lane plates. The choice of method was independent of the extent of soft tissue damage. A follow-up examination of 199 fractures, with a mean observation time of 3.4 years, revealed residual malalignment in 21 per cent of conservatively treated cases and in 8 per cent after conventional plate fixation, while the AO method resulted in anatomical restoration of the axis of the tibia in all cases. However, removal of the compression plates was followed by re-fractures, early and late, in 11 per cent. Implant failure occurred in 5 per cent of both types of plate fixation, and 3 per cent of the conservatively treated cases redislocated. Infection developed in 5 per cent of closed fractures and in 11 per cent of open fractures treated by operative means. Of the conservatively treated cases, only 3 per cent of the open fractures developed infection. The risk of infection following acute internal fixation is thus four times greater than with conservative treatment. AO compression plate fixation shortened the time of fracture healing considerably. The rate of non-union after conservative treatment was 6 per cent in closed and 21 per cent in open fractures. Similarly in conventional plate fixation there was non-union in 8 and 24 per cent, respectively. Non-union was not encountered after AO compression plate osteosynthesis. It is concluded that AO plate osteosynthesis is justified in the treatment of open tibial shaft fractures and also useful in closed fractures when conservative treatment does not lead to stable reduction with a good alignment.

A PROGNOSTIC EVALUATION OF THE HOSPITAL RESOURCES REQUIRED FOR THE TREATMENT OF HIP FRACTURES

A retrospective study of 1,592 hip fracture patients over the age of 50 years was undertaken, recording the age and sex, the fracture type and treatment, the hospitalization time and the rate of technical failures. Based on the predicted population in the area of admission it was calculated that the number of hip fractures will double within the next 17 years. An analysis of the hospitalization time in relation to the various types of treatment and the rate of technical failures made it possible to calculate the hospital resources required in the future. It was found that despite the considerable increase in the number of hip fractures treatment can be undertaken without further allotment of resources provided a rationalized treatment plan is instituted aiming at the safest possible methods of treatment, as the hospitalization time was found to be considerably influenced by technical failures of the treatment.

Mortality After Major Amputation Following Gangrene of the Lower Limb

Major amputations were performed on 310 patients because of gangrene of the lower limb. The mean age was 70 years and 58 per cent of the patients were males. Females were on average 5 years older. The primary levels of amputation were above-knee (AK) in 33 per cent (103/310), through-knee (TK) in 21 per cent (66/310) and below-knee (BK) in 46 per cent (141/310). Mortality during hospitalization was 18 per cent and the average hospitalization time 68 days. Mortality during hospital stay was primarily dependent on the occurrence of somatic complications, secondarily on the level of the amputation (as an expression of the extent of the gangrene) and finally on the age of the patient. The long-term survival rate was correlated primarily to the level of the amputation and secondarily to age. A high excess mortality was noted during the first few postoperative years, especially among AK amputees, but after this period the survival curve ran parallel to the expected survival rate. Mortality after 1 year was 34 per cent, comprising 17 per cent after BK amputation, 39 per cent after TK and 54 per cent after AK amputation.

Evaluation of polypropylene prostheses designed by the International Committee of the Red Cross for trans–tibial amputees

Thirtyue4f8two (32) trained prosthesis users with 34 transue4f8tibial amputations, mostly due to war, were fitted with prostheses fabricated from polypropylene (PP) prosthetic components designed and manufactured by the International Committee of the Red Cross (ICRC). The patients were followed prospectively for 10 and 19 months. All but one patient had at least one other type of prosthesis to compare with. Twentyue4f8eight (28) patients were satisfied with the PP prosthesis. Among these 23 found the PP prosthesis the preferred artificial limb, and one patient found the PP limb equal to the aluminium prosthesis previously in use. In 6/28 patients having an aluminium (ALU) prostheses this was found the best, and the 1 already mentioned found it equivalent to the new technology. In only 1/20 cases having an Automated Fabrication of Mobility Aids (AFMA) prosthesis available this was found the best. One (1) doubleue4f8amputee found all three designs equal. Minor failures of the PP prostheses were encountered; in 4 cases small cracks in the hard socket; in 3 cases cracks of the cosmetic socket seam. From an overall prospect the PP technology can be recommended for transue4f8tibial prostheses.

Wound healing complications following major amputations of the lower limb

A series of 320 amputations was analyzed with regard to wound healing complications and re-amputation rates. Among 111 AK amputations complications in wound healing were encountered in 14 per cent (15/111) of the cases, leading to re-amputation in 2 per cent (2/111). TK amputations were followed by wound healing problems in 30 per cent (20/66) of the cases with re-amputation in 20 per cent (13/66) at AK level, as compared to 40 per cent (57/143) with wound healing complications and 20 per cent (28/143) re-amputations in BK-amputees. As failure of BK amputation leads to re-amputation at AK level it is recommended that the TK level be selected in doubtful cases.

Mechanical testing of prosthetic feet utilized in low-income countries according to ISO-10328 standard

This report summarizes the results from 1132 ISO-10328 standard tests performed on 21 different prosthetic foot models commonly utilized in the developing world. None of the tested feet passed the strictest ISO testing protocol. All but one failed at the initial Static Proof test, which simulates a single momentary overload, due to permanent forefoot deformation. In addition, all tested feet had significant internal failures that were visible when sectioned longitudinally. Static Proof testing revealed average permanent deformation of the forefoot of all feet that exceeded the optional 5 mm ISO requirement. Forefoot deformation for non-Jaipur rubber feet came closest to meeting the standard at 8.3±3.4 mm; deformation of the various types of rubber Jaipur feet was the greatest at 22.5±5.4 mm. Forefoot deformation for polyurethane (PU) feet was 13.6±5.5 mm. Forefoot deformation of the ethyl-vinyl-acetate (EVA) feet was slightly greater than the Jaipur feet at 22.8±5.7 mm. After the Static Strength test, which simulates a higher momentary overload, permanent deformation of the feet increased. The average maximum deformation for rubber SACH forefeet varied from 17 – 30 mm, and 11 – 26 mm for the heel; Jaipur forefeet 47 – 60 mm and heels 13 – 19 mm; PU forefeet 20 – 44 mm and heels 20 – 33 mm; and EVA forefeet 33 – 50 mm and heels 16 – 31 mm. After completion of the Cyclic Test the prosthetic feet were sawn in half and closely examined visually. All feet revealed internal derangements: (i) Deformation of rubber or PU foam under the keel of forefoot and/or heel: HCMC, VI, EB1, BAVI, HI Cambodia, Myanmar, Angola, TATCOT, Kingsley and CR; (ii) Delamination from the keel: Mozambique, PHN, and Pro-cirugia; and (iii) Delamination between foam layers: BMVSS, NISHA, MUKTI, and OM. The influence of the two environmental factors tested was minimal for rubber feet with respect to deformation and inconsistent for the polymer feet; in particular for the forefeet. Creep increased with humidity exposure in some feet of natural rubber. However, creep decreased with ultraviolet (UV) exposure for these natural rubber feet, as was also the case for EVA feet, whereas the creep increased for two PU feet. Comparison of the effect of humidity and UV exposure generally showed less creep with UV exposure. In conclusion, ISO-10328 testing prior to release of a new foot construction for amputee use appears to be useful in the developing countries as well as in the developed world, even though it does not simulate the wear on the plantar surface that is seen clinically in barefoot walking. Inspection of the internal structures after the laboratory testing has been shown to reveal occult failure mechanisms in all tested feet.