P. Jalovaara

Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients

The aim of this prospective matched-pair (age, sex, fracture type, residential status, and walking ability at fracture) study was to analyse the short-term outcome after Gamma nail (GN) and dynamic hip screw (DHS) fixation, focusing especially on functional aspects (Standardised Audit of Hip Fractures in Europe [SAHFE] hip fracture follow-up forms), reoperations, and mortality. Both groups consisted of 134 patients. DHS and GN groups did not differ significantly with respect to location of residence at 4xa0months or returning to the prefracture dwelling (78% vs. 73%, Pu2009=u20090.224). The change in walking ability at 4xa0months compared to prefracture situation was better in the DHS group (pu2009=u20090.042), although there was no difference in the change of use of walking aids. The frequency of reoperations during the first year was somewhat lower in the DHS group (8.2% vs. 12.7%, pu2009=u20090.318). Mortality was lower in the DHS group both at 4xa0months (6.0% vs. 13.4%, pu2009=u20090.061) and 12xa0months (14.9% vs. 23.9%, pu2009=u20090.044). Although walking ability was better and mortality lower in the DHS group, both methods are useful in the treatment of trochanteric femoral fractures.RésuméLe but de cette étude prospective est de comparer et d’analyser le devenir à long terme des fractures du col fémoral traitées par clou Gamma (GN) ou par le vis plaque (DHS), notamment en ce qui concerne leurs aspects fonctionnels, les réinterventions et la mortalité. Deux groupes de 134 patients ont été comparés. Il n’y a pas de différence significative entre ces deux groupes à 4 mois en ce qui concerne le retour aux activités pré-opératoires (78% vs. 73%, Pu2009=u20090.224) entre DHS et GN. Néanmoins, la marche à 4 mois est bien meilleure dans le groupe DHS (pu2009=u20090.042), il n’y a pas de différence en ce qui concerne l’utilisation d’aide à la marche, moins de réinterventions dans le groupe DHS (8,2% vs. 12,7%, pu2009=u20090.318), de même en ce qui concerne la mortalité (6,0% vs. 13,4%, pu2009=u20090.061) et à 12 mois (14,9% vs 23,9%, pu2009=u20090.044). Ces deux méthodes sont utiles dans le traitement des fractures cervico trochantériennes, néanmoins, l’amélioration de la marche et la mortalité sont bien meilleures dans le groupe GHS que dans le groupe clou gamma.

Hip fractures in Finland and Great Britain – a comparison of patient characteristics and outcomes

Abstract. All hip fracture patients (age <50 years, pathological and subtrochanteric fractures excluded) were registered at admission to hospital and at 4 months (mortality up to 1 year) between 1989 and 1997 in Peterborough District Hospital (2083 patients) and Oulu University Hospital (1702 patients). The mean age at fracture was 80.3 years in Peterborough and 78.3 years in Oulu. Respectively, 69% and 62% of the patients had been living in their own homes, 50% and 54% had been able to walk alone unassisted. In Oulu, the patients were discharged after a mean stay of 7.1 days, most of them to health care centre hospitals (71%) and only 21% to their original place of residence. In Peterborough 81% were discharged to their original place of residence after a mean stay of 15.6 days. At 4 months, 54% were living at their own homes in Peterborough and 44% in Oulu. The overall mortality at 1 year was 27.1% in Peterborough and 24.9% in Oulu.Résumé. Tous les patients de moins de 50 ans avec une fracture de la hanche ( fractures pathologiques et sous-trochantériennes exclues) ont été suivi pendant quatre mois à partir de ladmission (mortalité jusquà une année) durant la période 1989–1997 dans le Peterborough District Hôpital (2083 patients) et le Oulu Université Hôpital (1702 patients). Lâge moyen à la fracture était 80.3 années à Peterborough et 78.3 années à Oulu. Respectivement, 69% et 62% des patients vivaient à leur domicile, 50% et 54% étaient capables de marcher seul. A Oulu, les patients ont eu un séjour moyen de 7.1 jours, et pour la plupart dentre eux (71%) sont allés ensuite dans des hopitaux de suite et seulement 21% à leur résidence originale. A Peterborough 81% ont regagné leur résidence initiale après un séjour moyen de 15.6 jours. À quatre mois, 54% habitaient à leur propre domicile après traitement à Peterborough et 44% après traitement à Oulu. La mortalité totale à une année était 27.1% pour Peterborough et 24.9% pour Oulu.

Early excision of the radial head for fracture

Abstractu2002The wrists and elbows of 23 patients were examined at a mean follow-up of 5 years (2–10 years) after excision of the radial head for an isolated fracture. Fourteen elbows and 13 wrists were symptomatic. Proximal migration of the radius was seen in 15 cases; the mean distance of migration being 1.4 mm. Osteoarthritis, mostly mild, was seen in 17 elbows and 14 wrists and limited movement of the elbow was a common finding. Excision of the radial head for fracture had a high complication rate.Résuméu2008u2008Le poignet et le coude de 23 malades ont été examinés à une période de suivi moyenne de 5 années (2–10 années) après une excision de la tête radiale pour une fracture isolée: 13 poignets étaient douloureux; 19 coudes étaient symptomatiques, mais dans la moitié des cas, la douleur était légère. On a constaté une migration proximale du radius dans 15 cas, la distance moyenne de migration étant de 14 mm. Une arthrose, généralement légère, fut notée à 17 coudes et 14 poignets. On observa également souvent une limitation de la mobilité du coude. L’excision de la tête radiale en raison d’une fracture entraîne un nombre élevé de plaintes postopératoires. Les indications de cette intervention devraient être relativement limitées.

Staged method using antibiotic beads and subsequent autografting for large traumatic tibial bone loss: 22 of 23 fractures healed after 5-20 months.

Introduction The vascularity of surrounding soft tissues, which is related to muscle cover, is important for the healing of traumatic bone loss. Muscle cover on the distal tibia is limited compared to the diaphyseal and proximal tibia, and delayed healing of fractures in this area is common. We evaluated the healing of traumatic bone loss in the proximal, diaphyseal, and distal tibia. Patients and methods 23 open tibial fractures with substantial bone loss (mean 52 (34–104) mm) were treated using a staged method with antibiotic-impregnated beads and later autologous bone grafting at second-stage surgery on average 8 weeks after the injury. Results 22 fractures healed after mean 40 (20–79) weeks. The average healing time in the distal tibia (mean 30 weeks) was 7 weeks shorter (95% CI: 12–26 weeks) than in the proximal tibia (37 weeks), and 16 weeks shorter (95% CI: 3–29 weeks) than in the tibial shaft (47 weeks). The length of the bone and the type of soft tissue cover (free muscle or secondary suture) had no effect on healing time. Interpretation Our study suggests that the method we used is applicable in all parts of the tibia, although the healing of bone loss is slower in the diaphyseal tibia than in the proximal and distal tibia.

Basicervical fracture – a rare type of hip fracture

Abstract. Basicervical fracture is a controversial type of hip fracture, which can be regarded as either extracapsular or intracapsular. It is seldom mentioned in the authorized orthopaedic textbooks, and it lacks an exact definition in the most commonly used classifications. The aim of this study was to evaluate the rate of basicervical hip fractures and the methods of treating them in a prospective series of 1624 consecutive hip fractures. Standardized forms were used to collect information, including the classification of fracture types. Initially, 108 fractures were classified as basicervical, but a careful second-look check revealed that 51 were transcervical fractures, while 27 fractures had a trochanteric extension. Thus, 30 of the fractures fulfilled the criteria of basicervical fracture (rate 1.8%). The 14 fractures treated as extracapsular fractures (dynamic hip screw, DHS, or gamma nail) showed a better outcome than the 16 treated as intracapsular fractures (hemiarthroplasty or screw osteosynthesis). We conclude that basicervical fracture of the hip is a very uncommon entity, but it is worth considering and should be treated as a trochanteric fracture.

Surgical treatment of resistant tennis elbow. A prospective, randomised study comparing decompression of the posterior interosseous nerve and lengthening of the tendon of the extensor carpi radialis brevis muscle.

Abstract We compared decompression of the posterior interosseous nerve (PIN) and lengthening of the distal tendon of the extensor carpi radialis brevis (ECRB) for treatment of tennis elbow in a randomised trial of 28 patients. Fourteen underwent decompression of PIN and 14, lengthening of ERCB. The groups did not differ significantly with regard to age, sex and work activities. The average duration of preoperative symptoms was 23 months. The PIN was exposed in the groove between the brachioradialis and brachialis muscles and decompressed at the arcade of Frohse by means of a 1–2 cm incision through the supinator muscle. The ECRB tendon was lengthened by Z-plasty at the dorsilateral aspect of the forearm. No postoperative complications occurred. The outcome after the primary operation was successful in 50% of the PIN group and in 43% of the ECRB group. Four of the 5 patients with a poor outcome were reoperated in the former group and 3 in the latter. The overall outcome after a mean follow-up of 31 months after the primary operation was successful in 60% of the cases.

Hemiarthroplasty or osteosynthesis in cervical hip fractures: matched-pair analysis in 892 patients.

Abstract. Our aim was to compare hemiarthroplasty (HA) and osteosynthesis (OS) in the treatment of cervical hip fractures using matched-pair analysis, especially with regard to different age groups. Data concerning all hip fractures (excluding pathological fractures) at the University Hospitals of Lund in Sweden, where osteosynthesis with LIH hook-pins was used exclusively, and of Oulu in Finland, using mainly cementless Austin-Moore hemiarthroplasty, were registered during 1989–1996 using the same standardized hip fracture forms filled in preoperatively and at 4xa0months follow-up. Altogether 446 pairs matched for age, sex, place of residence and walking ability at the time of fracture were found. Patients aged 55–80xa0years seemed to benefit more, with regard to function, from OS than older patients. At 4xa0months follow-up, 38% of HA and 48% of OS patients lived in their own homes, 16% and 27% were able to walk alone outdoors, and 11% versus 16% were able to walk without any aids, respectively. At 1xa0year follow-up, mortality was significantly lower among the OS patients, but the reoperation rate was significantly higher. In conclusion, OS is associated with a better function and lower mortality than HA, especially in younger patients, and it is recommended as the primary treatment for cervical hip fractures in patients younger than 80xa0years and with good ambulatory capacity, whereas the oldest patients can also be safely treated by HA.

Risk factors for cervical and trochanteric hip fracture during a fall on the hip.

Objective - The aim of this study was to elucidate factors related to hip fracture in patients who fall on the hip in order to identify those patients who might benefit from the use of hip protectors. Design - The study was performed by comparing 146 persons who had fallen and sustained a soft tissue injury in the hip region with 146 cervical hip fracture and 146 trochanteric hip fracture patients matched for age, sex and place of residence. Patients - The fall group was drawn from a prospectively collected cohort of 1061 elderly people participating in an epidemiological survey on fall injuries; the fracture group was drawn from a prospectively recorded hip fracture database of the Oulu University Hospital (n = 1714). Outcome measures - Demographic data, place and mechanism of falling, walking ability, associated diseases, medication. Results - In a stepwise polychotomous conditional logistic regression analysis, the following significant and independent risk factors for both fracture types were seen: low weight, tall height, falling from standing height and respiratory disease. Falling indoors was a risk for only trochanteric fractures, while inability to walk alone outdoors was a risk for only cervical hip fractures. Conclusions - Elderly persons with low weight, tall height, respiratory disease, tendency to fall indoors and inability to walk alone outdoors should be candidates for the use of hip protectors.

Geriatric and physically oriented rehabilitation improves the ability of independent living and physical rehabilitation reduces mortality: a randomised comparison of 538 patients

Objective: To examine effects of physical and geriatric rehabilitation on institutionalisation and mortality after hip fracture. Design: Prospective randomised study. Setting: Physically oriented (187 patients), geriatrically oriented (171 patients), and health centre hospital rehabilitation (180 patients, control group). Subjects: A total of 538 consecutively, independently living patients with non-pathological hip fracture. Main measures: Patients were evaluated on admission, at 4 and 12 months for social status, residential status, walking ability, use of walking aids, pain in the hip, activities of daily living (ADL) and mortality. Results: Mortality was significantly lower at 4 and 12 months in physical rehabilitation (3.2%, 8.6%) than in geriatric rehabilitation group (9.6%, 18.7%, P=0.026, P=0.005, respectively) or control group (10.6%, 19.4%, P=0.006, P=0.004, respectively). At 4 months more patients in physical (84.4%) and geriatric rehabilitation group (78.0%) were able to live at home or sheltered housing than in control group (71.9%, P=0.0012 and P<0.001, respectively). No significant difference was found between physical rehabilitation and geriatric rehabilitation (P=0.278). Analysis of femoral neck and trochanteric fractures showed that significant difference was true only for femoral neck fractures (physical rehabilitation vs geriatric rehabilitation P=0.308, physical rehabilitation vs control group P<0,001 and geriatric rehabilitation vs control group P<0.001). Effects of intensified rehabilitations disappeared at 12 months. No impact on walking ability or ADL functions was observed. Conclusions: Physical rehabilitation reduced mortality. Physical and geriatric rehabilitation significantly improved the ability of independent living after 4 months especially among the femoral neck fracture patients but this effect could not be seen after 12 months.

Costs after hip fracture in independently living patients: A randomised comparison of three rehabilitation modalities

Objective: To evaluate costs and cost-effectiveness of physical and geriatric rehabilitation after hip fracture. Design: Prospective randomised study (mean age 78 years, 105 male, 433 female) in different rehabilitation settings: physically oriented (187 patients), geriatrically oriented (171 patients), and healthcare centre hospital (control, 180 patients). Main measures: At 12 months post-fracture, we collected data regarding days in rehabilitation, post-rehabilitation hospital treatment, other healthcare service use, number of re-operations, taxi use by patient or relative, and help from relatives. Results: Control rehabilitation (4945,2€) was significantly less expensive than physical (6609.0€, p=0.002) and geriatric rehabilitation (7034.7€ p<0.001). Total institutional care costs (primary treatment, rehabilitation, and post-rehabilitation hospital care) were lower for control (13,438.4€) than geriatric rehabilitation (17,201.7€, p<0.001), but did not differ between control and physical rehabilitation (15659.1€, p=0.055) or between physical and geriatric rehabilitation (p=0.252). Costs of help from relatives (estimated as 30%, 50% and 100% of a home aid’s salary) with physical rehabilitation were lower than control (p=0.016) but higher than geriatric rehabilitation (p=0.041). Total hip fracture treatment costs were lower with physical (36,356€, 51,018€) than control rehabilitation (38,018€, 57,031€) at 50% and 100% of salary (p=0.032, p=0.014, respectively). At one year post-fracture, 15D-score was significantly higher in physical rehabilitation group (0.697) than geriatric rehabilitation group (0.586, p=0.008) and control group (0.594, p=0.009). Conclusions: Considering total costs one year after hip fracture the treatment including physical rehabilitation is significantly more cost-effective than routine treatment. This effect could not be seen between routine treatment and treatment including geriatric rehabilitation.