Fixation of displaced subcapital femoral fractures. Compression screw fixation versus double divergent pins.

One hundred and twenty-seven consecutive patients with displaced subcapital fractures of the femoral neck (Garden Grade III or IV) all under 80 years of age and independently mobile, were randomly allocated to fixation with either double divergent pins or a single sliding screw-plate device. The incidence of non-union and infection in the sliding screw-plate group was significantly higher, and we believe that when internal fixation is considered appropriate multiple pinning should be used. Mobility after treatment was disappointing in about half of the patients, and we feel that internal fixation can only be justified in patients who are physiologically well preserved and who maintain a high level of activity.

An orthopaedic geriatric rehabilitation unit: the first two years experience.

Experience of the first two years of an orthopaedic geriatric rehabilitation unit is described. There were 325 admissions comprising 271 females and 54 males. The predominant diagnosis was fracture of the proximal femur. Average length of stay in the unit was 43 days for males and 36.7 days for females. 75.9% of patients admitted from home returned there and 66.1% of patients admitted from residential care returned to similar accommodation. In the first year there was a fall of 13.5 days in the average length of stay for elderly females with proximal femoral fracture, resulting in 2175 less bed days for this diagnosis. This improvement has continued.

Primary total hip replacement for displaced subcapital fractures of the femur.

The management of displaced subcapital fracture of the hip is still controversial because of the high incidence of complications after internal fixation or hemiarthroplasty. To avoid some of these complications we have used primary total hip replacement for independently mobile patients over 65 years of age. A total of 163 cases, operated on over four years, have been reviewed. There were relatively more dislocations after operation for fracture than after total replacement for arthritis, and these were associated with a posterior approach to the hip. Only seven revision operations have been required. Of 57 patients who were interviewed an average of 42 months after replacement, 62% had excellent or good results as assessed by the Harris hip score. All the others had major systemic disease which affected their assessment. This inadequacy of current systems of hip assessment is discussed. It is concluded that total hip replacement is the best management for a selected group of patients with this injury, and that further prospective studies are indicated.

Activation of latent collagenase by serum proteinases that interact with immobilized immunoglobulin G.

It has been previously observed that collagen destruction occurs in the vicinity of immune complexes present in articular cartilages of patients with rheumatoid arthritis. When IgG is covalently linked to Sepharose it behaves as if it has reacted with an antigen to form an immune complex, in that it binds the complement component C1 from human serum. Other serum components also interact with this matrix, though their interaction may not be specific for IgG. Two of these components were shown to possess proteolytic activity, one being kallikrein and the other having the properties of plasmin. Both of the activities could activate latent human collagenase. Whilst the binding of the plasmin activity is probably nonspecific, the binding of the kallikrein activity may be selective for IgG (although it is not certain whether this binding is direct or indirect via another molecule). These results therefore suggest that active proteinases such as plasma kallikrein may be selectively concentrated on immune complexes in vivo, where they may locally activate latent proteinases such as collagenase thereby initiating tissue destruction.