Tania A. Ferguson

Fractures of the acetabulum in patients aged 60 years and older: AN EPIDEMIOLOGICAL AND RADIOLOGICAL STUDY

Using a prospective database of 1309 displaced acetabular fractures gathered between 1980 and 2007, we calculated the annual mean age and annual incidence of elderly patients > 60 years of age presenting with these injuries. We compared the clinical details and patterns of fracture between patients > 60 years of age (study group) with those < 60 years (control group). We performed a detailed evaluation of the radiographs of the older group to determine the incidence of radiological characteristics which have been previously described as being associated with a poor patient outcome. In all, 235 patients were > 60 years of age and the remaining 1074 were < 60 years. The incidence of elderly patients with acetabular fractures increased by 2.4-fold between the first half of the study period and the second half (10% (62) vs 24% (174), p < 0.001). Fractures characterised by displacement of the anterior column were significantly more common in the elderly compared with the younger patients (64% (150) vs 43% (462), respectively, p < 0.001). Common radiological features of the fractures in the study group included a separate quadrilateral-plate component (50.8% (58)) and roof impaction (40% (46)) in the anterior fractures, and comminution (44% (30)) and marginal impaction (38% (26)) in posterior-wall fractures. The proportion of elderly patients presenting with acetabular fractures increased during the 27-year period. The older patients had a different distribution of fracture pattern than the younger patients, and often had radiological features which have been shown in other studies to be predictive of a poor outcome.

Predictors of clinical and radiological outcome in patients with fractures of the acetabulum and concomitant posterior dislocation of the hip

We aimed to identify variables associated with clinical and radiological outcome following fractures of the acetabulum associated with posterior dislocation of the hip. Using a prospective database of 1076 such fractures, we identified 109 patients with this combined injury managed operatively within three weeks and followed up for two or more years. The patients had a mean age of 42 years (15 to 79), 78 (72%) were male, and 84 (77%) had been involved in motor vehicle accidents. Using multivariate analysis the quality of reduction of the fracture was identified as the only significant predictor of radiological grade, clinical function and the development of post-traumatic arthritis (p < 0.001). All patients lacking anatomical reduction developed arthritis whereas only 25.5% (24 patients) with an anatomical reduction did so (p = 0.05). The quality of the reduction of the fracture is the most important variable in forecasting the outcome for patients with this injury. The interval to reduction of the dislocation of the hip may be less important than previously described.

Optimal treatment of femoral neck fractures according to patient's physiologic age: an evidence-based review.

For decades, the basic tenets of managing displaced femoral neck fractures have not changed, but the optimal treatment choice continues to be highly debated. The contemporary controversies associated with the treatment principles of displaced femoral neck fractures are distinct between young and old patients and are considered individually in this article about the current evidence. Although fixation constructs all seem to have similar complication rates, there is increasing evidence suggesting that total hip replacement improves patient functional outcomes for healthy, independent, elderly patients compared with hemiarthroplasty and should be considered as the treatment of choice for these patients.

Fragility fractures of the pelvis

Fragility fractures of the pelvis are common and the incidence is increasing with the aging population. The primary risk factor is osteoporosis. Diagnosis is challenging and advanced imaging with computed tomography (CT), bone scintigraphy, and magnetic resonance imaging (MRI) is helpful. These injuries result in significant morbidity, including prolonged hospitalization, immobility, and loss of autonomy in previously active patients. The mortality rate is high, similar to hip fracture patients. This problem is underappreciated and deserves attention. An opportunity exists to improve outcomes with medical and surgical management.

Surgical Timing of Treating Injured Extremities

After more than a decade of conflicting publications as well as changes in institutional resources, surgeons rightly question the ideal timing of surgical intervention for various extremity injuries. Is this fracture a true emergency? Can it wait until tomorrow morning? Is definitive management best delayed to minimize further trauma to the patient’s physiology or soft tissues? And how does the availability of protected, daytime operating-room time influence these decisions? To address these questions, we evaluated the evidence regarding the optimal or critical time for surgical intervention in treating various extremity injuries and the influence of a designated orthopaedic trauma room on management strategies. ### Compartment Syndrome Compartment syndrome of the extremities remains a true orthopaedic surgical emergency. While innovative treatments continue to be developed, little has changed in the diagnosis and management. Once the diagnosis is made, fasciotomy and evaluation of muscle viability is emergent; there are few indications for treatment delay except for a patient in extremis. #### Diagnosis Diagnosis of compartment syndrome remains clinically challenging, and despite technological developments in pressure detection instruments, physical examination and clinical history remain the mainstays of diagnosis. One of the challenges of diagnosis is physical examination in patients who cannot reliably communicate, such as those who are intubated or those with altered sensorium. In these patients, examination can be unreliable1. Additionally, the so-called classic clinical findings, such as changes on vascular examination or paralysis, occur late and are less helpful in preventing morbidity. Pain out of proportion with passive stretch of an involved muscle group is one of the earliest and most sensitive clinical signs1. Paresthesias are an early sign and likely related to nerve ischemia2. Patients can develop compartment syndromes acutely after injury, after fracture fixation, or in a delayed fashion1,3. Although a specific measured value …

Contemporary management of femoral neck fractures: the young and the old

The optimal management strategy for femoral neck fractures remains highly debated. The femoral neck is intracapsular and the vascular supply is fragile. Furthermore, the curvature of the proximal femur results in high mechanical stresses through the femoral neck. Poor outcomes of nonunion and avascular necrosis (AVN) are common. This chapter reviews the current evidence with respect to the treatment principles of femoral neck fractures in two distinct patient populations: “young” and “old.” Contemporary controversies including surgical timing, choice of implant, arthroplasty options, nonoperative management, capsulotomy, and associated complications will be discussed.

Decision making open reduction/internal fixation versus arthroplasty for femoral neck fractures

Summary: Femoral neck fractures account for half of all hip fractures with a rapidly increasing incidence. Since they are associated with high mortality, decrease in quality of life, and high total costs, much research on the optimal treatment of these fractures has been undertaken. In this article, we provide a summary of the available evidence comparing open reduction and internal fixation and arthroplasty. We focus on the treatment of displaced femoral neck fractures in active, healthy elderly patients. Additionally, we discuss treatment options for patients with undisplaced femoral neck fractures, younger patients, and patients with cognitive impairments. Furthermore, we present cost-effectiveness analyses on the treatment of these fractures, comparing both costs and patient benefits between internal fixation and different arthroplasty approaches.

Observational Studies in Orthopaedic Surgery: The STROBE Statement as a Tool for Transparent Reporting

Evidence-based medicine in orthopaedic surgery comprises predominantly observational studies. While the gold standard of study methodology is considered to be randomized controlled trials (RCTs), observational studies provide valuable information regarding disease prevalence and etiology, rare outcomes, and adverse treatment effects. Orthopaedic surgeons care for many diseases and injuries that are rare and will likely never be the subject of an RCT. Given the bias to which observational studies are prone, however, transparent reporting is imperative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement is a checklist of items that can help clinician-scientists to improve the transparency with which observational studies are reported. We offer the following guidelines and examples for how the STROBE statement can be applied to reporting observational studies in orthopaedic surgery. Observational studies inform clinicians about disease etiology, natural history, prognostic factors, and treatment effectiveness1,2. The most common observational study designs include cohort, case-control, and cross-sectional studies. In a cohort study, subjects are divided into two groups, or cohorts: those with an exposure of interest and those without. The groups are then followed prospectively and are observed for an outcome of interest. In a case-control study, subjects who have experienced an outcome (cases) are matched with subjects who have not experienced an outcome (controls). The two groups are then studied retrospectively to determine a causal relationship between unmatched risk factors and the outcome of interest. In a cross-sectional study, each subject in a population is evaluated at a single point in time, often to calculate the prevalence of disease or to establish an association between risk factors and outcome. Observational studies, specifically, case series, predominate the surgical literature in both general surgery (46%) and orthopaedic surgery (88%)2-4. One reason for the high prevalence of observational studies …

Evidence-based medicine. Implants for fixation of femoral neck fractures

Summary: Most orthopaedic surgeons utilize parallel cannulated partially threaded screws for fixation of femoral neck fractures, both in the young and elderly patient. The clinical results of this approach, however, are far from ideal. It is helpful for the surgeon to have a good understanding of a comparison between the various fixation options which are available, and to understand future potential fixation alternatives. The clinical results of patients with these fractures may be improved with improved fixation methods in the future.

Symphysis pubis width in the pediatric population: A computerized tomography study.

BACKGROUND Defining pathologic widening of the pubic symphysis in the pediatric population continues to be a clinical challenge. The purpose of this study is to define a normal range of pubic symphyseal widths in various age and gender groups using axial computerized tomography (CT) scans. METHODS Axial CT images of 140 patients aged between 2 years and 15 years were obtained from our database of preexisting scans. Using a commercially available software package, the single image with the narrowest pubic symphyseal width was identified and measured. Patients were further stratified based on gender and by age into three groups: group A (age 2–5 years), group B (age 6–11 years), and group C (age 12–15 years). RESULTS The mean width ± 95% confidence interval for all cases was 4.59 mm ± 0.18 mm. The mean width for male and female patients was 4.86 mm ± 0.26 mm and 4.33 mm ± 0.24 mm, respectively. Based on the two-way analysis of variance, both age group and gender had a statistically significant effect. Post hoc testing demonstrated a statistically significant difference in mean symphyseal width between groups A and C (p < 0.0001) and groups B and C (p = 0.0025) but not between groups A and B (p = 0.055). When grouped by age, the mean male pubic symphyseal width was found to be 5.10 mm, 4.93 mm, and 4.45 mm, while the mean female width was found to be 4.94 mm, 4.33 mm, and 3.54 mm at 2 to 6 years, 7 to 11 years, and 12 to 15 years of age, respectively. CONCLUSION In the pediatric population, males seem to have a wider pubic symphysis than females of the same age group. In both males and females, pubic symphyseal width decreases during the transition from infancy toward skeletal maturity. LEVEL OF EVIDENCE Epidemiologic study, level III.