John P. Lyden

Diagnosis of occult fractures about the hip : magnetic resonance imaging compared with bone-scanning

Sixty-two consecutively seen patients in whom a fracture about the hip was clinically suspected, but in whom the radiographic findings were negative, were examined with both magnetic resonance imaging and bone-scanning. The magnetic resonance-imaging studies, consisting of T1-weighted coronal sections, were done within twenty-four hours after admission to the hospital, and the bone scans, within seventy-two hours after admission. There were twenty-three men and thirty-nine women. Thirty-six patients who had evidence of a fracture on the magnetic resonance-imaging study also had a positive bone scan initially. Twenty-three patients who had a negative finding on the magnetic resonance-imaging study had a corresponding negative bone scan. Two additional patients had evidence of avascular necrosis of the femoral head on both the magnetic resonance image and the bone scan, and they were managed non-operatively. One patient had a positive magnetic resonance image and a negative bone scan twenty-four hours after admission. A repeat bone scan, which was made six days later, was positive for a fracture of the femoral neck and the patient was managed with internal fixation. Magnetic resonance imaging was as accurate as bone-scanning in the assessment of occult fractures of the hip. The magnetic resonance imaging took less than fifteen minutes to perform, and it was tolerated well by the patient. Magnetic resonance imaging provides an early diagnosis of occult fractures about the hip and may decrease the length of the stay in the hospital by expediting definitive treatment.

Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly.

This paper presents the short term results of an ongoing prospective randomized trial comparing a cemented unipolar with a cemented bipolar hemiarthroplasty for the treatment of displaced femoral neck fractures in the elderly. Forty-seven patients with an average age of 77 years completed 6-month followup. Outcomes at 6 weeks, 3 months and 6 months were assessed by completion of a patient oriented hip outcome instrument and by functional tests of walking speed and endurance. No differences in the postoperative complication rates or lengths of hospitalization were seen between the two groups. Patients treated with a bipolar hemiarthroplasty had greater range of hip motion in rotation and abduction and had faster walking speeds. However, no differences in hip rating outcomes were found. These early results suggest that use of the less expensive unipolar prosthesis for hemiarthroplasty after femoral neck fracture may be justified in the elderly.

Bipolar hemiarthroplasty for fracture of the femoral neck. Clinical review with special emphasis on prosthetic motion.

The results of a consecutive series of 120 bipolar replacements of the femoral head that had been done for the treatment of a fracture of the femoral neck were reviewed. Ninety patients were followed for a minimum of two years. At the latest follow-up, eighty-two (91 per cent) of the patients were free of major pain, and eighty-three (92 per cent) were considered to have satisfactory motion and muscle power. Postoperative function often was limited by underlying medical problems. Seventy-five patients (83 per cent) either returned to the level of function that they had had before the fracture or used only a cane, which they had not needed previously. There was no important deterioration of the results with time. For twenty-six of the prostheses, roentgenograms were made with the patient bearing weight in order to determine the relative motion at the two sites of articulation of the bipolar prosthesis. The roentgenograms demonstrated the presence and maintenance of motion at both bearing surfaces.

Bipolar hemiarthroplasty for fracture of the femoral neck.

Controversy in the treatment of displaced femoral neck fractures in the elderly focuses on the use of fixation versus the use of a prosthesis. Beginning in 1980, at The New York Hospital-Cornell Medical Center, it became routine to treat elderly patients for displaced fractures with bipolar hemiarthroplasty. This retrospective study evaluates the morbidity, mortality, and clinical and social functioning of 246 consecutive patients treated with bipolar hemiarthroplasty for Garden III and Garden IV nonpathological fractures. Follow-up ranged from 1 to 6 years. Of the 246 patients with 247 femoral neck fractures, 201 were female and 45 were male; the average age was 78 years. Fourteen patients (5.7%) died during the postoperative hospitalization. Thirty-one patients (13.3%) died within the first year following surgery. Mortality was related to the number of preexisting medical conditions: patients with four or more preexisting conditions had a significantly higher mortality than others (p less than 0.001: chi 2). The overall wound infection rate was 3.2%. There were only two failures (0.9%), both for deep infection, requiring Girdlestone debridement. One patient was revised for infection with successful reimplantation. There were two postoperative dislocations (0.9%), both reduced closed. Only one bipolar (0.4%) required conversion to a total hip replacement for a fractured acetabulum, none for arthritic wear. No radiographic evidence of significant acetabular erosion or protrusion nor femoral component loosening was noted. Clinical results were evaluated using the Hospital for Special Surgery Hip Rating Scale.(ABSTRACT TRUNCATED AT 250 WORDS)

Subtrochanteric fracture after cannulated screw fixation of femoral neck fractures: a report of four cases

Subtrochanteric fractures after screw or pin fixation of femoral neck fractures are a recognized complication. No literature is available on this complication after fixation using the recently popularized cannulated screws. We present our experience in treating four of these complications. The common denominator for all four patients seemed to be an entry point in the lateral cortex below the level of the most inferior edge of the lesser trochanter.

The short term outcome of elderly patients with hip fractures.

Abstract A prospective outcome study was performed of 100 hip fracture patients at an urban medical center in the United States. After hospitalization 19% were discharged to a rehabilitation facility and 59% were discharged home. At a mean follow-up of 8 months, 81% of patients lived at home, compared to 89% who lived at home prior to the fracture. At follow-up 71% of the patients were able to walk outside with one cane or no aids at all, and 81% were able to perform basic activities of daily living. Half of all patients did not require any home assistance at follow-up. Ten patients had died at follow-up. The goal of operatively treating the patient with a hip fracture is fixation of the fracture with a return to the patient’s pre-fracture functional ability. This study illustrates that patients with hip fractures can be effectively treated and discharged home or to a short-term rehabilitation facility with restoration of their pre-fracture functional status.Résumé  Une étude prospective sur le devenir de 100 patients présentant une fracture de la hanche a été faite dans un Centre Médical Urbain des USA. Après l’hospitalisation, 19% des patients sont allés en structure de rééducation et 59% ont regagné leur domicile. A un délai moyen de 8 mois, 81% des patients vivent à domicile alors qu’il y en avait 89% avant la fracture. Au délai d’observation, 71% des patients marchent à l’extérieur avec une canne ou sans aide et 81% sont capables des activités habituelles de la vie quotidienne. La moitié des patients n’ont besoin d’aucune assistance à domicile. 10 patients sont morts. Le but du traitement opératoire des patients présentant une fracture de la hanche est la fixation de la fracture pour permettre un retour au niveau de fonction pré-traumatique. Cette étude confirma la possibilité d’un retour à l’état fonctionnel antérieur avec, aprés le traitement, un retour à domicile ou un court séjour en Centre de réadaptation.

Long bone fracture in a spinal-cord-injured patient: complication of treatment--a case report and review of the literature.

Long bone fractures in patients with spinal cord injuries are difficult to manage. A case is presented in which complications arose after a femur fracture in a paraplegic patient was treated by closed fixation in a long leg circular plaster cast and the literature on management of long bone fractures in patients with spinal cord injuries is reviewed.

Postoperative femoral fracture after intramedullary fixation with a Gamma nail: case report and review of the literature.

The Gamma nail, an intramedullary nail that is combined with a sliding hip screw, has recently been introduced as an alternative method of treatment for peritrochanteric fractures of the femur. We report a case of a postoperative femoral fracture that occurred in the area of the device after Gamma nailing of a stable intertrochanteric fracture. A review of the literature reveals that postoperative fracture is not an uncommon complication of Gamma nailing. This complication results in a difficult management problem. The possibility of a femoral fracture around the Gamma nail should be entertained before the use of the nail is considered. The availability of alternative fixation devices must be confirmed in the event that such a fracture is encountered.

A biomechanical evaluation of the long stem intramedullary hip screw.

Summary: Despite the advantages associated with short-stem intramedullary hip screw devices for the treatment of intertrochanteric fractures, recent reports have shown an increased incidence of femoral shaft fractures after their insertion. These findings led to the hypothesis that an intramedullary hip screw with a longer stem may more effectively redistribute loads to the distal end of the femoral shaft, where they may be more readily absorbed by the increased bony cross-sectional area. To characterize the load patterns of a long-stem device in the femur, 10 fresh-frozen adult femurs were instrumented with unidirectional strain gauges. A total of eight strain gauges were placed in the direction of principal femoral strains on the medial and lateral surfaces of each femur. Each femur was held in a steel vice at 15° of adduction in the coronal plane and vertical in the sagittal plane. The femurs were then subjected to successively increasing vertically applied compressive loads from 0 N to 1,400 N at 200-N increments using a servohydraulic testing machine. Strain values were recorded at each load after a 5-min equilibration period. Each femur was tested under five conditions: (a) intact, (b) after insertion of the long-stem intramedullary hip screw device, (c) with an experimentally created two-part fracture, (d) with a stable four-part fracture, and (e) with an unstable four-part fracture with the posteromedial fragment removed. Half the femurs were randomly assigned to have two distal interlocking screws placed before fracture. The remaining half were loaded without distal interlocking screws. The results indicate that the loads on the femur with intertrochanteric fractures are redistributed such that the proximal femur is subjected to significantly lower strains. Moreover, even though strain values in the distal metaphysis at the site of load transfer were relatively high, they did not differ significantly from the values recorded in the intact femur. Thus, the long-stem intramedullary hip screw device transmits progressively decreasing load to the proximal femur with increasing fracture instability and redistributes this load throughout the distal femur without significantly increasing distal femoral strain values

Intertrochanteric fractures of the hip treated with the hip compression screw: analysis of problems.

Seventy-five patients were treated for intertrochanteric hip fractures with the hip compression screw. There were 4 cases in which the lag screw was inserted twice into the femoral head. Three of these patients had a poor result due to superolateral migration and extrusion of the lag screw. The fact that the lag screw is large in comparison to the femoral head makes double placement dangerous. Satisfactory guide wire placement is essential for a one time, precise insertion of the lag screw into the femoral head. The use of a threaded tip guide wire minimizes the chance of it falling out when withdrawing the reamer or tap. If the position of a lag screw is unacceptable, it seems better to insert a flanged nail rather than a second screw in a second track.