Martin Gargan

Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial.

BACKGROUNDnHemiarthroplasty and total hip arthroplasty are commonly used to treat displaced intracapsular fractures of the femoral neck, but each has disadvantages and the optimal treatment of these fractures remains controversial.nnnMETHODSnIn the present prospectively randomized study, eighty-one patients who had been mobile and lived independently before they had sustained a displaced fracture of the femoral neck were randomized to receive either a total hip arthroplasty or a hemiarthroplasty. The mean age of the patients was seventy-five years. Outcome was assessed with use of the Oxford hip score, and final radiographs were assessed.nnnRESULTSnAfter a mean duration of follow-up of three years, the mean walking distance was 1.17 mi (1.9 km) for the hemiarthroplasty group and 2.23 mi (3.6 km) for the total hip arthroplasty group, and the mean Oxford hip score was 22.3 for the hemiarthroplasty group and 18.8 for the total hip arthroplasty group. Patients in the total hip arthroplasty group walked farther (p=0.039) and had a lower (better) Oxford hip score (p=0.033) than those in the hemiarthroplasty group. Twenty of thirty-two living patients in the hemiarthroplasty group had radiographic evidence of acetabular erosion at the time of the final follow-up. None of the hips in the hemiarthroplasty group dislocated, whereas three hips in the total hip arthroplasty group dislocated. In the hemiarthroplasty group, two hips were revised to total hip arthroplasty and three additional hips had acetabular erosion severe enough to indicate revision. In the total hip arthroplasty group, one hip was revised because of subsidence of the femoral component.nnnCONCLUSIONSnTotal hip arthroplasty conferred superior short-term clinical results and fewer complications when compared with hemiarthroplasty in this prospectively randomized study of mobile, independent patients who had sustained a displaced fracture of the femoral neck.

THE BEHAVIOURAL RESPONSE TO WHIPLASH INJURY

We studied 50 consecutive patients presenting at an accident department after rear-end vehicle collisions and recorded symptoms and psychological test scores within one week of injury, at three months and at two years. The range of neck movement was noted at three months. Within one week of injury, psychological test scores were normal in 82% of the group but became abnormal in 81% of the patients with intrusive or disabling symptoms at over three months (p < 0.001) and remained abnormal in 69% at two years. The clinical outcome after two years could be predicted at three months with 76% accuracy by neck stiffness, 74% by psychological score and 82% by a combination of these variables. The severity of symptoms after a whiplash injury is related both to the physical restriction of neck movement and to psychological disorder. The latter becomes established within three months of the injury.

Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: A SEVEN- TO TEN-YEAR FOLLOW-UP REPORT OF A PROSPECTIVE RANDOMISED CONTROLLED TRIAL

We reviewed the seven- to ten-year results of our previously reported prospective randomised controlled trial comparing total hip replacement and hemiarthroplasty for the treatment of displaced intracapsular fracture of the femoral neck. Of our original study group of 81 patients, 47 were still alive. After a mean follow up of nine years (7 to 10) overall mortality was 32.5% and 51.2% after total hip replacement and hemiarthroplasty, respectively (p = 0.09). At 100 months postoperatively a significantly greater proportion of hemiarthroplasty patients had died (p = 0.026). Three hips dislocated following total hip replacement and none after hemiarthroplasty. In both the total hip replacement and hemiarthroplasty groups a deterioration had occurred in walking distance (p = 0.02 and p < 0.001, respectively). One total hip replacement required revision compared with four hemiarthroplasties which were revised to total hip replacements. All surviving patients with a total hip replacement demonstrated wear of the cemented polyethylene component and all hemiarthroplasties had produced acetabular erosion. There was lower mortality (p = 0.013) and a trend towards superior function in patients with a total hip replacement in the medium term.

Soft-tissue injuries of the cervical spine

Forty patients with a whiplash injury who had been reviewed previously 2 and 10 years after injury were assessed again after a mean of 15.5 years by physical examination, pain and psychometric testing. Twenty-eight (70%) continued to complain of symptoms referable to the original accident. Neck pain was the commonest, but low-back pain was present in half. Women and older patients had a worse outcome. Radiating pain was more common in those with severe symptoms. Evidence of psychological disturbance was seen in 52% of patients with symptoms. Between 10 and 15 years after the accident 18% of the patients had improved whereas 28% had deteriorated.

Factors affecting employment after whiplash injury

Of 586 employed patients with a whiplash injury 40 (7%) did not return to work. The risk was increased by three times in heavy manual workers, two and a half times in patients with prior psychological symptoms and doubled for each increase of grade of disability. The length of time off work doubled in patients with a psychological history and trebled for each increase in grade of disability. The self-employed were half as likely to take time off work, but recovered significantly more slowly than employees.

SOFT-TISSUE INJURIES OF THE CERVICAL SPINE

Forty patients with a whiplash injury who had been reviewed previously 2 and 10 years after injury were assessed again after a mean of 15.5 years by physical examination, pain and psychometric testing.nnTwenty-eight (70%) continued to complain of symptoms referable to the original accident. Neck pain was the commonest, but low-back pain was present in half. Women and older patients had a worse outcome. Radiating pain was more common in those with severe symptoms.nnEvidence of psychological disturbance was seen in 52% of patients with symptoms. Between 10 and 15 years after the accident 18% of the patients had improved whereas 28% had deteriorated.

Factors predicting outcome after whiplash injury in subjects pursuing litigation

Records of 277 patients presenting for medicolegal reporting following isolated whiplash injury were studied retrospectively. A range of pre-accident, accident and response variables were recorded. Multivariate analysis was used to determine the main factors that predict physical and psychological outcome after whiplash injury. The factors that showed significant association with poor outcome on both physical and psychological outcome scales were pre-injury back pain, high frequency of General Practitioner attendance, evidence of pre-injury depression or anxiety symptoms, front position in the vehicle and pain radiating away from the neck after injury. The strongest associations were with factors that are present before impact. In this selected cohort of patients, there is a physical and a psychological vulnerability that may explain the widely varied response to low violence indirect neck injury.

Arthrodesis of the distal tibiofibular joint for a large osteochondroma in an adult.

A case of a large osteochondroma of the distal tibia with distortion of the distal tibiofibular joint is presented. This could not be managed by traditional means, as excision would have resulted in ankle and tibiofibular joint instability. The problem was overcome by performing an arthrodesis. Only enough bone from both the tibia and the fibula was excised to provide a host bed for bone graft. We believe that symptomatic osteochondromata should usually be excised. However, if this would result in damage, then the method described offers an alternative management strategy.

The role of physiotherapy in the treatment of whiplash associated disorders: a prospective study

ObjectivesProspective longitudinal study to evaluate the effect of physiotherapy on whiplash associated disorders (WAD).Materials and methodsA total of 141 patients suffering from grades I–III WAD after a road traffic accident were employed. Validated neck Bournemouth Questionnaire was used in order to look at the effect of treatment on the symptoms.ResultsThe mean age was 40 (±14) years. The mean length of the treatment was 6 (±3.4) weeks. The mean individual effect size was 0.97 (95% CI 0.8–1.2). A total of 67% of the patients who started their treatment in the first 3xa0months post-injury improved compared to 48% in those who started physiotherapy after 3xa0months (Pxa0=xa00.025). In both groups the applied treatment almost halved the number of patients taken sick leave.ConclusionPhysiotherapy is effective in the treatment of whiplash injury, especially in order to get the patients fit to go back to their previous employment.