Stein Øvre

Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up.

Objective To determine if any differences exist in healing and complications between reamed and unreamed nailing in patients with tibial shaft fractures. Design Prospective, randomized. Setting Level 1 trauma center. Patients Forty-five patients with displaced closed and open Gustilo type I–IIIA fractures of the central two thirds of the tibia. Intervention Stabilization of tibial fractures either with a slotted, stainless steel reamed nail or a solid, titanium unreamed nail. Main Outcome Measurements Nonunions, time to fracture healing, and rate of malunions. Results The average time to fracture healing was 16.7 weeks in the reamed group and 25.7 weeks in the unreamed group. The difference was statistically significant (P = 0.004). There were three nonunions, all in the unreamed nail group. Two of these fractures healed after dynamization by removing static interlocking screws. The third nonunion did not heal despite exchange reamed nailing 2 years after the primary surgery and dynamization with a fibular osteotomy after an additional 1 year. There were two malunions in the reamed group and four malunions in the unreamed group. There were no differences for all other outcome measurements. Conclusion Unreamed nailing in patients with tibial shaft fractures may be associated with higher rates of secondary operations and malunions compared with reamed nailing. The time to fracture healing was significantly longer with unreamed nails.

Cemented femoral impaction bone grafting for severe osteolysis in revision hip arthroplasty. Good results at 4-year follow-up of 10 patients.

Abstract Ten hips underwent impaction bone grafting with cement as revision of the femoral stem for severe osteolysis. At clinical follow-up of a median of 4 years (range 3.0–4.6 years) there were no failures. The median Harris hip score increased from 53 to 80, and pain score from 25 to 40. Radiographically, there was no resorption of the impacted grafts. All of the 9 patients with radiographical follow-up of more than 1 year showed trabecular remodelling, 7 of whom had signs of cortical repair. Subsidence was a median of 2 mm, with the maximum subsidence being 5 mm. The results appeared clinically stable after 4 years with radiographic reconstitution of the bone stock.

Acetabular fracture displacement, roof arc angles and 2 years outcome

Four hundred and fifty acetabular fractures in a prospectively recorded cohort were studied. Forty-one patients had died, 201 had a follow-up of more than 2 years and 25 were excluded which left a study population of 176 patients. Harris Hip Score (HHS) and modified HHS were used as outcome instruments. Acetabular fracture displacement and roof arc angles converted into a Roof Arc Score were assessed and correlated with clinical outcome at 2 years follow-up. For surgically treated fractures with residual steps and diastases after operation the correlation between steps and 2 year outcome was good. The location of fracture lines in the acetabular dome, expressed as a Roof Arc Score, proved to be more important than the residual step for 2 years clinical outcome (p<0.05). The impact of location of fracture lines in the acetabular dome on clinical outcome disappeared when open reduction and internal fixation (ORIF) resulted in a perfect anatomic reduction, i.e. without any residual steps or diastases assessed in the three radiographic views. The general association between fracture diastases and functional outcome was poor, except for non-operatively treated fractures without measurable steps.

Obturator neuropathy due to intrapelvic extrusion of cement during total hip replacement--report of 2 patients.

A 64-year-old man was referred to our department in August 1997 because of persistent pain after THA. He had sustained a femoral neck fracture in May 1992, which was operated on with closed reduction and internal ” xation with 3 screws. In February 1993 the patient received a Charnley/Hastings hemiarthroplasty due to non-union. In June 1994, he was revised with a Charnley femoral stem and an OGEE-cup because of aseptic loosen-ing. On evalua tion in August 1997, he complained about increasing pain after the last operation. The pain was sharp, worse with activity, located in the groin and it radiated down the medial aspect of the thigh. No changes had occurred on the plain radiographs since the postoperative ones. A large amount of cement was seen medial to the acetabu-lum (Figure 1). Entrapment of the obturator nerve was suspected, and a CT scan showed medial dis-

Acetabular fracture assessment in four different pelvic trauma centers: have the Judet views become superfluous?

IntroductionThe present study was designed to examine whether oblique radiographs (Judet views) in addition to 2D and 3D CT scans improved the intra- and interobserver reliability when assessing acetabular fractures.Materials and methodsFour international orthopedic pelvic trauma centers reviewed the radiological images for 20 acetabular fracture patients. Three different image sets were made; one set containing plain radiographs including oblique (Judet) views and 2D axial CT scans. The second set contained an AP radiograph of the pelvis, without oblique views, 2D and 3D CT scans. The third set contained all the images. The image sets were evaluated in three separate sessions, for each session the raters were asked to classify the fracture according to Letournel, as well as record a number of other important radiological features concerning the fracture.ResultsThe interobserver agreement for the Letournel classification was found to be moderate for all image sets. The image set without oblique views showed the best agreement with a kappa value of 0.60. The intra- and interobserver agreement for important modifiers were found to be substantial. The addition of oblique radiographs did not seem to increase the intra- or interobserver agreement for any of the factors evaluated except for the roof arc score.ConclusionThe moderate agreement found for the Letournel classification is to be expected given the complexity of the classification. The addition of oblique radiographs to the image sets does not seem to improve the reliability and thus its routine use for classification and decision making may be debated.

Transitional transverse acetabular fractures: Differences between fractures with a large posterio-superior fragment and the inverse T-fracture—a report of 10 unusual cases

Background Classification of fractures is crucial in decision making and planning of acetabular surgery. Transverse fractures with secondary vertical fracture lines—which constitute either a large posterio-superior fragment (floating dome) or an inverse T with the posterior ileum attached to the axial skeleton—have not been described in detail in the literature. Methods All acetabular fractures at Ullevål University Hospital have been recorded prospectively since 1993 and classified according to Judet/Letournel. Results In 10/449 fractures (2%) there was a transverse fracture line through the acetabulum, with an additional vertical fracture line ascending either to the iliac crest or the SI-joint. In 6 of these fractures the vertical line started within the acetabulum, and the posterior part of the ileum with part of the articular surface was attached to the axial skeleton. In 4 fractures the vertical fracture line started posterior to the joint, constituting a very large posterio-superior fragment without any articular surface (a floating dome). Interpretation Open reduction and internal fixation of inverse T-fractures and transverse fractures with a floating dome require different surgical approaches. The latter can be treated through a single approach alone, while the inverse T-fracture may require extensile or combined approaches for adequate reduction and fixation.   ▪

The natural history of bone bruise and bone remodelling in the traumatised hip: A prospective 2-year follow-up study of bone bruise changes and DEXA measurements in 13 patients with conservatively treated traumatic hip dislocations and/or fractures

INTRODUCTION The purpose of this study was to assess the natural history of bone bruise and bone mineral density (BMD) after traumatic hip dislocations and conservatively treated acetabular fractures. Our hypothesis was that poor bone quality can influence degree of bone bruise and, in time, cause degenerative changes. MATERIALS AND METHODS Eight consecutive patients with traumatic hip dislocations and five patients with conservatively treated fractures in the femoral head and/or acetabulum were included. Magnetic resonance imaging (MRI) was obtained after 1, 17, 42, 82 and 97 weeks. Dual-emission X-ray absorptiometry (DXA) measurements were made after 10 days and 2 years. Sizes of bone bruise lesions were measured and classified. At the 2-year follow-up, Harris hip score (HHS) was calculated and signs of radiological osteoarthritis (OA) registered. RESULTS The bone bruise changes were small and all changes resolved within 42 weeks in all, except for three patients; one with a small Pipkin fracture had segmental avascular necrosis (AVN) of the femoral head, one had persisting1-3mm small spots of bone bruises in the femoral head and the third had <1cm lesions in both the femoral head and the acetabulum. The lesions were bigger in the femoral head in the hip dislocations and more pronounced in the acetabulum in the fractured acetabuli. We found no significant changes in BMD in four regions of interest (ROIs) after 2 years. No patients developed OA, and all had excellent HHS except for the one patient with AVN. CONCLUSION The post-traumatic bone bruise changes in the dislocated hips and the fractured acetabuli were small and transient compared to findings of other authors examining traumatised knees. The patients had excellent function and no OA after 2 years if they did not develop AVN. In our small sample of relatively young patients with normal age-adjusted BMD, no post-traumatic osteopenia was observed. This might differ in the elderly with poorer bone quality; further studies are needed to assess that.