Peter Gebuhr

Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures: An Important Predictor of a Reoperation

BACKGROUND Reoperations after intertrochanteric fractures are often necessitated by fracture displacement following mobilization of the patient. The biomechanical complexity of the fracture, the position of the implant, and the patients characteristics are known to influence postoperative outcome. We investigated the importance of an intact lateral femoral wall as a factor in postoperative fracture displacement after fixation with a sliding compression hip screw. METHODS Two hundred and fourteen consecutive patients with an intertrochanteric fracture were treated with a 135 degrees sliding compression hip screw with a four-hole side-plate between 2002 and 2004. The fractures were classified on preoperative radiographs according to the AO/OTA classification system. The status of the greater and lesser trochanters, the integrity of the lateral femoral wall, and the position of the implant were assessed postoperatively. Reoperations due to technical failure were recorded for six months postoperatively. RESULTS Only 3% (five) of 168 patients with an intact lateral femoral wall postoperatively underwent a reoperation within six months, whereas 22% (ten) of forty-six patients with a fractured lateral femoral wall were operated on again (p < 0.001). Multivariate logistic regression analyses combining demographic and biomechanical parameters showed a compromised lateral femoral wall to be a significant predictor of a reoperation (p = 0.010). Seventy-four percent (thirty-four) of the forty-six fractures of the lateral femoral wall occurred during the operative procedure itself. A fracture of the lateral femoral wall occurred in only 3% (three) of the 103 patients with an AO/OTA type-31-A1.1, A1.2, A1.3, or A2.1 intertrochanteric fracture compared with 31% (thirty-one) of the ninety-nine with an AO/OTA type 31-A2.2 or A2.3 fracture (p < 0.001). CONCLUSIONS A postoperative fracture of the lateral femoral wall was found to be the main predictor for a reoperation after an intertrochanteric fracture. Consequently, we concluded that patients with preoperative or intraoperative fracture of the lateral femoral wall are not treated adequately with a sliding compression hip-screw device, and intertrochanteric fractures should therefore be classified according to the integrity of the lateral femoral wall, especially in randomized trials comparing fracture implants.

The prevalence of cam-type deformity of the hip joint: a survey of 4151 subjects of the copenhagen osteoarthritis study:

Background: Cam deformity is a preosteoarthritic malformation causing premature hip-joint degeneration. While the pathogenetic pathway from deformity to osteoarthrosis (OA) has been well established, almost nothing is known of the malformations epidemiology. Purpose: To determine the distribution of cam deformity in a large, unselected cohort from standardized anteroposterior (AP) pelvic radiographs. Material and Methods: The distribution of cam deformity was assessed in 3202 (1184 male, 2018 female) standardized AP pelvic radiographs using the triangular index (TI) and the α angle. The relationships between cam malformation and self-reported hip pain were evaluated, and the relative importance of known risk factors for cam malformation estimated. Results: We found a pronounced sex-related difference in cam-deformity distribution. The overall prevalence of cam deformity was approximately 17% in men and 4% in women. The distribution of cam deformity was unaltered in subjects with normal joint-space width or other features of hip-joint degeneration. We found no significant association with self-reported hip pain, nor did we find any relative importance of possible risk factors for hip deformity, such as body-mass index (BMI), occupational exposure to heavy workloads, or concomitant acetabular dysplasia. Conclusion:The results lend support to the thesis that cam deformity represents a silent slipped capital epiphysis, predominantly in men, and that it is a far from uncommon deformity in subjects with no apparent evidence of hip-joint osteoarthritis.

Hip dysplasia and osteoarthrosis: A survey of 4 151 subjects from the osteoarthrosis substudy of the Copenhagen city heart study

Introduction Hip dysplasia (HD) is assumed to be an etiological factor in the development of premature hip osteoarthrosis (OA). We established the prevalences of HD and OA in adults according to qualified radiographic discriminators, and investigated the relationship between HD and OA. Methods Wiberg′s CE angle (CE), Sharp′s angle, the femoral head extrusion index, the acetabular depth ratio (ADR), the radiographic OA discriminators of Croft, and of Kellgren and Lawrence, and also minimum joint space width (JSW) ≤ 2 mm were applied to the standing, standardized pelvic radiographs of 1 429 men (22-93 years), and 2 430 women (22-92 years). Results The 4 HD discriminators were interrelated. A negligible sex-related difference in acetabular morphology was found, male acetabulae being slightly more dysplastic than female acetabulae. However, differences between the sexes for right and left CE angles were within 1.0°, and within 1.4° for right and left Sharp′s angles. There were no cases of hip subluxation (breakage of Shenton′s line ≥ 5 mm). Average CE angle was 34° in men (SD 7.3°), and 35° in women (SD 7.6°). Applying a CE cut-off value of 20° for designation of definite hip dysplasia, we found a prevalence of hip dysplasia of 3.4%. Approximately 2% of cases were unilateral and 1.4% of cases were bilateral. We found significant relationships between radiographic OA discriminators and the CE angle, femoral head extrusion index and ADR. Odds ratios ranged from 1.0 to 6.2. Compared to subjects with OA in morphologically normal hips, a trend towards younger age in subjects with HD and OA was noted, but this was not strictly significant. Interpretation We found that HD is not uncommon in the general population. The assumption that HD is an etiological factor in the development of hip OA was confirmed.

Degenerative lumbar spondylolisthesis: an epidemiological perspective: the Copenhagen Osteoarthritis Study.

Study Design. A cross-sectional epidemiological survey of 4151 participants of the Copenhagen Osteoarthritis Study. Objective. To identify prevalences and individual risk factors for degenerative lumbar spondylolisthesis. Summary of Background Data. The Copenhagen Osteoarthritis Study has registered health parameters since 1976. In 1993, standardized, lateral radiographs of the lumbar spine were recorded. There were 1533 men and 2618 women. Methods. Statistical correlations were made between degenerative spondylolisthesis, and physical, occupational, and general epidemiological data. Results. A total of 254 cases of lumbar slip were found (males 2.7%, females 8.4%). In females, no significant relationship between age at menopause or childbirths and the presence of degenerative spondylolisthesis were found. In women, relationships between body mass index (BMI) in 1976 and L4 olisthesis (P = 0.001), and between BMI in 1993 and both L4 and L5 olisthesis were found (L4: P = 0.003; L5: P = 0.006). Lumbar lordosis was associated with degenerative spondylolisthesis in women. Occupational exposures to daily lifting or smoking were not associated with degenerative spondylolisthesis. Degenerative spondylolisthesis was associated with increased age in both sexes (L4: P < 0.001; L5: P < 0.001). Conclusions. BMI longitudinally and at index evaluations, age, and angle of lordosis were significantly associated with degenerative spondylolisthesis in women. In men, no individual risk factors for degenerative spondylolisthesis were found, save increased age.

Tranexamic acid reduces blood loss and blood transfusions in primary total hip arthroplasty: a prospective randomized double-blind study in 40 patients.

Introduction: We performed a prospective, randomized, double-blind study on 40 patients scheduled for primary total hip arthroplasty due to arthrosis or osteonecrosis to determine the effect of tranexamic acid on per- and postoperative blood losses and on the number of blood transfusions needed. Patients and methods: 40 patients were randomized to tranexamic acid (10 mg/kg given as a bolus intravenous injection, followed by a continuous infusion of 1 mg/kg/hour for 10 hours) or placebo (20 mL saline given intravenously) 15 minutes before the incision. We recorded the peroperative and postoperative blood losses at removal of the drain 24 hours after the operation and the number of blood transfusions. Results: Patients receiving tranexamic acid had a mean peroperative blood loss of 480 mL versus 622 mL in patients receiving placebo (p= 0.3), a postoperative blood loss of 334 mL versus 609 mL (p= 0.001), a total blood loss of 814 mL versus 1231 mL (p= 0.001) and a total need for 4 blood transfusions versus 25 (p= 0.04). No patient in either group had symptoms of deep venous thrombosis, pulmonary embolism or prolonged wound drainage. Interpretation: Transemic acid is effective in reducing the postoperative blood loss, the total blood loss and the need for blood transfusion in primary total hip arthroplasty.

Radiographic case definitions and prevalence of osteoarthrosis of the hip: a survey of 4 151 subjects in the Osteoarthritis Substudy of the Copenhagen City Heart Study.

Background The diagnosis of osteoarthrosis (OA) is founded on radiographic evidence of joint degeneration and characteristic subjective symptoms. Due to the lack of consensus radiographic case definitions, the prevalence and incidence of OA reported in the literature varies. The aims of the current study were to establish an accurate and workable radiographic definition of OA in hip joints and to examine the association of OA (thus defined) with self-reported pain. Methods Radiographic features of hip OA were classified in pelvic radiographs of 3 807 subjects (1 448 males and 2 359 females) according to the OA classifications of Kellgren and Lawrence (1957) and Croft (1990), and according to minimum joint space width (JSW) of 2.0 mm regardless of other radiographic features of OA. The relationships between these radiographic discriminators and self-reported hip pain were investigated. Results Formation of cysts, osteophytes and subchondral sclerosis was significantly more frequent in men. Average minimum JSW was narrower in women than in men (p < 0.001). In both sexes, minimum JSW decreased after the fourth decade of life, but progressively more so in women. Women reported hip pain more frequently than men (p < 0.001). When the cut-off JSW value of 2.0 mm was applied regardless of other radiographic features of OA, prevalences of hip OA ranged from 4.4% to 5.3% in subjects ≥ 60 years of age. The radiographic discriminator with the strongest association with self-reported hip pain in men and women ≥ 60 years of age was minimum JSW ≤ 2.0 mm; OR = 3.3 (95% CI 1.9 − 5.7) for men, and OR = 3.2 (95% CI 1.9 − 5.2) for women. Interpretation We found that minimum JSW ≤ 2.0 mm was the radiographic criterion having the closest association with self-reported hip pain. Using composite OA scores emphasizing the relatively inconsequential formation of cysts, osteophytes and subchondral sclerosis runs the risk of over-inflating the prevalence of hip OA in men and of underestimating hip OA prevalence in women.

Very low survival rates after non-traumatic lower limb amputation in a consecutive series: what to do? †

The aim of this retrospective study was to evaluate factors potentially influencing short- and long-term mortality in patients who had a non-traumatic lower limb amputation in a university hospital. A consecutive series of 93 amputations (16% toe/foot, 33% trans-tibial, 9% through knee and 42% trans-femoral) were studied. Their mean age was 75.8 years; 21 (23%) were admitted from a nursing home and 87 (92%) were amputated due to a vascular disease and/or diabetes. Thirty days and 1-year mortality were 30 and 54%, respectively. Cox regression analysis demonstrated that the 30-day mortality was associated with older age (P = 0.01), and the number of co-morbidities (P = 0.04), when adjusted for gender, previous amputations, cause of and amputation level, and residential status. Thus, a patient with 4 or 5 co-morbidities (n = 20) was seven times more likely to die within 30 days, compared with a patient with 1 co-morbidity (n = 16). Further, the risk of not surviving increased with 7% per each additional year the patient got older. Of concern, almost one-third of patients died within 1 month. This may be unavoidable, but a multidisciplinary, optimized, multimodal pre- and postoperative programme should be instituted, trying to improve the outcome.

Heterotopic ossification after hip arthroplasty A randomized double-blind multicenter study of tenoxicam in 147 hips

147 patients due to have a cemented total hip arthroplasty were randomized to 4 groups. They received either tenoxicam 20 mg or 40 mg, or placebo, for 5 days or morphine on the day of operation and placebo for 4 days. During the first 5 days 14 patients were excluded. The patients were followed for 1 year, during which another 10 patients were excluded. At follow-up, significantly fewer patients had heterotopic ossifications in the tenoxicam groups than in the placebo and morphine groups. There was no significant difference between the 2 tenoxicam-treated groups, and we therefore conclude that tenoxicam 20 mg for 5 days postoperatively can reduce heterotopic ossification after cemented total hip arthroplasty.

Naproxen for 8 days can prevent heterotopic ossification after hip arthroplasty.

The effect of 1 week of treatment with naproxen on the formation of heterotopic ossification after cemented total hip arthroplasty was studied in a prospective trial. Twenty-seven patients received 500 mg naproxen twice daily for 7 days postoperatively. The medication was started on the morning of the operation. The results were compared with a control group of 23 patients from a previous study who had not received any type of nonsteroidal antiinflammatory drug. All radiographs were mixed randomly, and patient identification was blinded. Three months after the operation, heterotopic ossification had developed in 12 (52%) patients in the control group and in 3 (11%) patients in the naproxen-treated group. One year after the operation, 4 (17%) patients in the naproxen-treated group and 12 (52%) in the control group had heterotopic ossification (p < 0.05). Severe ossification developed in 3 patients in the control group and in none in the naproxen-treated group. The authors conclude that naproxen given for 1 week can decrease the incidence of heterotopic ossification after total hip arthroplasty.

A new measurement for posterior tilt predicts reoperation in undisplaced femoral neck fractures: 113 consecutive patients treated by internal fixation and followed for 1 year.

Background and purpose Preoperative posterior tilt in undisplaced (Garden I–II) femoral neck fractures is thought to influence rates of reoperation. However, an exact method for its measurement has not yet been presented. We designed a new measurement for posterior tilt on preoperative lateral radiographs and investigated its association with later reoperation. Patients and methods A consecutive series of 113 patients, ≥ 60 years of age with undisplaced (Garden I–II) femoral neck fractures treated with two parallel implants, was assessed regarding patient characteristics, radiographs, and rate of reoperation within the first year. In a subgroup of 50 randomly selected patients, reliability tests for measurement of posterior tilt were performed. Results Intra-and interclass coefficients for the new measurement were ≥ 0.94. 23% (26/113) of patients were reoperated and increased posterior tilt was an accurate predictor of failure (p = 0.002). 14/25 of posteriorly tilted fractures ≥ 20° were reoperated, as compared to 12/88 of fractures with less tilt (p < 0.001). In multiple logistic regression analysis including sex, age, ASA score, cognitive function, new mobility score, time from admission to operation, surgeons expertise, postoperative reduction, and implant positioning, a preoperative posterior tilt of ≥ 20° was the only significant predictor of reoperation (p < 0.001). Interpretation The new measurement for posterior tilt appears to be reliable and able to predict reoperation in patients with undisplaced (Garden I–II) femoral neck fractures.