Measuring recovery after a hip fracture using the SF-36 and Cummings scales.

The objective of this study was to assess outcomes of traditional treatment of fractures using the SF-36 and the Cummings Hip Scale. In designing randomized clinical trials, it is necessary to determine the timing of assessment either for progress or for the main outcome. We set out to document the recovery of patients after surgery for hip fracture using current standard methods of medical care. This was a prospective study of a cohort of patients. Patients who were receiving standard medical care completed the SF-36 and the Cummings Hip Scale at previously determined times postoperatively. The SF-36 has eight subscales, including assessments of physical function, physical role behaviors, bodily pain, mental health, social role, emotional role, vitality and general health. Thirty-eight patients completed the questionnaires at 1 year postoperatively as well as previous time points. On the Cummings Hip Scale and the physical function, bodily pain, mental health, social function, emotional role, vitality and general health subscales of the SF-36, recovery is near complete at 6 months. Only the physical role subscale differs, with a statistically significant difference between the values at 6 months and 1 year, (p = 0.02). Patients attained over 90% of the 1 year value by 6 months for all except the physical role subscale. The physical role subscale reached 85%. For a hip fracture patient who is on the road to recovery, the majority of the recovery has therefore taken place by 6 months.

Failure of bipolar hemiarthroplasty: a retrospective review of 31 consecutive bipolar prostheses converted to total hip arthroplasty.

Bipolar hemiarthroplasty has been widely used for the treatment of femoral neck fractures in elderly patients. Outcome studies show excellent results with near preoperative ambulation and lasting, painless hip function. However, what has only recently been considered is that, in some cases, failure of bipolar hemiarthroplasty may be due to wear of the thin, ultra-high-molecular weight polyethylene (UHMWPE) insert between the inner and outer bearings of the prosthesis with subsequent generation of particulate debris, periprosthetic osteolysis, and stem loos ening. We reviewed 31 consecutive bipolar hemiarthroplasties converted to total hip arthroplasties by a single surgeon between 1986 and 1994. The average time to failure was 38 months. Fifty-six percent of the cases showed radiographic evidence of osteolysis around the stem. Radiographic migration of the bipolar head of more than 1 mm into the pelvis, suggestive of cartilage wear, occurred in 67% of the cases. Among the patients with radiographic osteolysis and a loose stem at the time of revision, 92% showed a characteristic histiocytic and giant cell reaction to polyethylene particles in tissue obtained during surgery. The UHMWPE liners from the retrieved outer shells showed an average wear rate of 0.7 mm per year. Recent studies comparing bipolar to unipolar hemiarthroplasty show little difference between the two with regard to morbidity, mortality, or functional outcome. In light of our findings, it might be prudent to reconsider the design and indications for bipolar hemiarthroplasty.

Bone cells and matrices in orthopedic tissue engineering.

The ability to harvest and manipulate osteogenic cells gives clinicians the opportunity to harness capacity of these cells for targeted regeneration and repair of skeletal tissues. Further opportunities to optimize use of cells exist in the ability to design specialized matrices that act as conductive scaffolds. Realization of the full potential of engineered matrix materials and cell-matrix composites can provide new solutions to many clinical problems in skeletal reconstruction.

Major life events as antecedents to hip fracture.

BACKGROUND: This study sought to determine whether the number of antecedent life events reported in the year before hip fracture among elderly patients was normal for the population from which these patients derive. Major life events are events such as births, deaths, major financial dealings, and major health changes. METHODS: Life events reported in the year before a fall and hip fracture for 111 hip fracture patients were compared with those of a control sample of 90 nonfracture, community-dwelling ambulatory elderly. RESULTS: The total number of life events was higher in the hip fracture group (p = 0.0001) than in the community control group. Fracture was also associated with the number of events experienced (adjusted OR, 2.1; 95% CI, 1.6-2.7; p < 0.0007), notwithstanding age, marital status, and education. CONCLUSION: Older persons who had sustained a fall-related traumatic hip fracture experienced an increased number of major life events compared with a nonfracture population sample of community-dwelling elderly controls.

Osteoconductive materials and their role as substitutes for autogenous bone grafts.

The term osteoconduction applies to a three-dimensional process that is observed when porous structures are implanted into or adjacent to bone. Capillaries, perivascular tissues, and osteoprogenitor cells migrate into porous spaces and incorporate the porous structure with newly formed bone. The observed process is characterized by an initial ingrowth of fibrovascular tissue that invades the porous structure followed by the later development of new bone applied directly within it. This article reviews observations of commonly used osteoconductive matrices to increase understanding of this process.

Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly.

This paper presents the short term results of an ongoing prospective randomized trial comparing a cemented unipolar with a cemented bipolar hemiarthroplasty for the treatment of displaced femoral neck fractures in the elderly. Forty-seven patients with an average age of 77 years completed 6-month followup. Outcomes at 6 weeks, 3 months and 6 months were assessed by completion of a patient oriented hip outcome instrument and by functional tests of walking speed and endurance. No differences in the postoperative complication rates or lengths of hospitalization were seen between the two groups. Patients treated with a bipolar hemiarthroplasty had greater range of hip motion in rotation and abduction and had faster walking speeds. However, no differences in hip rating outcomes were found. These early results suggest that use of the less expensive unipolar prosthesis for hemiarthroplasty after femoral neck fracture may be justified in the elderly.

Current understanding of osteoconduction in bone regeneration.

Bone tissue is osteoconductive. In particular, cancellous bone with its porous and highly interconnected trabecular architecture allows easy ingrowth of surrounding tissues. When placed in an osseous environment, living tissue for the host bed migrates into the cancellous structure, which results in new bone formation and incorporation of that structure. This is the process of osteoconduction. The mineral and collagenous components of bone are osteoconductive. Osteoconduction also is observed in fabricated materials that have porosity similar to that of bone structure. Corallin ceramics, hydroxyapatite beads, and combinations of hydroxyapatite and collagen all have osteoconductive properties, and porous metals and biodegradable polymers. Osteoconduction appears to be optimized in devices that mimic not only bone structure, but also bone chemistry. The incorporation of calcium salts and collagen by osteoconductive matrices leads to more complete ingrowth with new bone formation.

Proper design of clinical trials for the assessment of bone graft substitutes.

To assess the effectiveness and safety of engineered bone graft substitutes proper, clinical trials will need to be performed. Although the randomized placebo controlled prospective clinical trial is the gold standard, clinical trials of this design are difficult to perform in the surgical setting. At this writing, several clinical trials evaluating bone graft materials have been performed, and much was learned toward improving the design of future studies. This article reviews alternatives to the placebo controlled randomized clinical trials in the surgical setting. The importance of long term surveillance is emphasized.

Effects of environmental heat and intake of tall fescue seed infested with Acremonium coenophialum on the acid-base status of young bulls.

Effects of high environmental temperature and dietary intake of tall fescue (Festuca arundinacea) seed containing the endophyte Acremonium coenophialum on bovine acid-base status were studied using 3 groups of bull calves (2 Simmental, 1 Angus). Experimental animals were housed in controlled-climate chambers and subjected to gradual increases in environmental temperature, first while being fed an endophyte-free diet and then while being fed a diet containing 17% endophyte-infested fescue seed. Marked acid-base disturbances were not observed in any animals. In general, Pco2, HCO3-, base excess, and arterial blood pH values were reduced in response to heat stress, both with endophyte-free and endophyte-containing diets. In most individuals anion gap increased. These results reflected metabolic compensation for mild chronic alveolar hyperventilation and retention of organic acids. These findings suggest that, under conditions similar to those found during the summer in central Missouri, normal cattle should not be at great risk of developing respiratory alkalosis or other severe acid-base disturbances as a result of heat stress and/or intake of tall fescue endophyte.

Tension-band wiring supplemented by lag-screw fixation of proximal humerus fractures: a modified technique.

Many of the current techniques of internal fixation of proximal humerus fractures employ tension-band wires to achieve secure fixation, allowing immediate postoperative exercise of the affected limb. The addition of a cancellous lag screw placed from the humeral shaft into the humeral head may have several advantages. In particular, this lag screw does not violate the subacromial space and provides for impaction and initial stability between the head and shaft. The technique described herein has been used in 13 patients aged 54 to 86 years with two- and three-part fractures. This technique uses a deltopectoral approach with manual impaction of the humeral head and shaft. A 6.5-mm AO screw is used for lag-screw fixation, and two 18-gauge stainless steel wires are passed beneath the rotator cuff and secured to the shaft distally through drill holes. Passive range of motion of the involved shoulder is begun on postoperative day 1, and active range of motion and strengthening are allowed after the fourth postoperative week. Tension-band wiring combined with lag-screw fixation affords sufficient fracture stability to allow early, aggressive rehabilitation. As a method of internal fixation, this technique may have particular advantages in elderly patients with osteoporosis.

Internal fixation of proximal humerus fractures using the screw-tension band technique.

Many of the current techniques of internal fixation of proximal humerus fractures use tension band wires to achieve secure fixation, allowing immediate postoperative exercise of the affected limb. In addition, the use of a cancellous lag screw placed from the humeral shaft into the humeral head may have several advantages. In particular, this lag screw does not violate the subacromial space and provides initial stability between the head and shaft, which facilitates placement of the tension band wires. This technique was used in 13 patients whose average age was 71 years (range 54-86). Follow-up averaged 20 months. Eight patients had two-part fractures and five patients had three-part fractures. This technique used a deltopectoral approach with manual impaction of the humeral head and shaft. A 6.5-mm AO screw was used for lag screw fixation in addition to two 18-gauge tension band wires: one placed through the tuberosities and one under the rotator cuff tendons. Passive range of motion of the involved shoulder was begun with the first postoperative week, and active range of motion and strengthening were allowed after the fourth postoperative week. At follow-up patients were evaluated for range of motion, function, pain, and radiographic appearance of the fracture. Average forward flexion was 160 degrees, external rotation was 46 degrees, and internal rotation was to the 10th thoracic vertebra. According to the functional scale proposed by Hawkins, 10 of the 13 patients had achieved a good result. Two of the remaining patients had a fair score, and one had a poor outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of experimental osteomyelitis with antibiotic-impregnated bone graft substitute.

The model of Norden was used to induce osteomyelitis in the left tibia of New Zealand White rabbits. Twenty-one days following inoculation, the animals had primary debridement and then were randomized into one of three treatment groups. Group I received no additional treatment; in Group II, plain hydroxyapatite beads were packed into the defect; and in Group III, gentamicin crobefat-loaded hydroxyapatite beads were packed into the defect. The animals were observed for 40 days after the primary debridement and then were killed. The intensity of infection was determined by swab cultures and quantitative bacterial cultures of the debrided material. At primary debridement, all of the animals in each group were equally infected. At the time of secondary debridement, only the animals in Group III had a statistically significant reduction in infection (p < 0.001). In this study, we demonstrated that an antibiotic-loaded osteoinductive ceramic bead can effectively eliminate bacteria from an osteomyelitic cavity.

Newest factors in fracture healing.

Natural selection has evolved a process of fracture healing that is characterized by callus formation and is enhanced by physical loading and motion at the fracture site. Internal fixation of fractures alters the biology of fracture healing, especially when rigid fixation using plates is performed. Intramedullary nails that allow some motion and loading usually are associated with callus formation. Plates that practically eliminate interfragmentary motion, however, prevent external periosteal callus formation. Primary osteonal healing can occur with plate fixation, but if interfragmental gaping of greater than 1 mm exists, delayed healing occurs. Closed treatment of fractures occasionally results in nonunion. In addition, physicians' high expectations for skeletal restoration have prompted vigorous research in areas of bone grafting, graft substitutes, and analysis of local and systemic factors that regulate fracture healing. A better understanding of the activity of bone morphogenetic protein and growth factors, such as transforming growth factor beta, will allow manipulation of the biology of healing to enhance the surgical treatment of skeletal trauma.

Protein depletion and metabolic stress in elderly patients who have a fracture of the hip.

A prospective study was performed to determine the effect of protein depletion and postoperative nutritional status on the outcome in sixty-three elderly patients who had been admitted to the hospital because of a fracture of the hip. The parameters that were used to determine the degree of protein depletion included levels of albumin, of prealbumin, and of transferrin; total lymphocyte count; and nitrogen-balance studies. The outcomes that were examined were the development of complications, the length of the stay in the hospital, the ability to return to the pre-fracture level of function, and over-all survivorship. The hypothesis was that the acute fracture and the subsequent operation are severe stresses in these elderly, often compromised patients. The results supported the hypothesis. Thirty-seven patients (58 per cent) in the study group were in a protein-depleted state during the period of hospitalization. The patients who were protein-depleted had a higher prevalence of complications, were less likely to return to their pre-fracture environment, and tended to stay in the hospital longer, as compared with the nonprotein-depleted patients. Survivorship analysis showed that protein-depleted patients had a significantly lower probability of survival one year after the fracture of the hip (p = 0.02). Elderly patients who sustain the trauma of a fracture of the hip should be managed appropriately with regard to intake of nutrients in the postoperative period.

Hip fracture in older persons. Does self-efficacy-based intervention have a role in rehabilitation?

Over 250,000 patients are hospitalized each year in the United States for treatment of a fractured hip, resulting in considerable medical, social, and economic costs to society. Most hip fractures occur among older persons who have fallen. The consequences of hip fractures due to falls by older persons include loss of confidence and the accompanying deterioration in global functional capacity for independent living. This article reviews the problem of hip fracture in the elderly and suggests that intervention approaches designed to enhance personal self-efficacy through patient education may have an important role to play in rehabilitation after hip fracture.

Cardiac arrest during hip arthroplasty with a cemented long-stem component. A report of seven cases.

Seven patients had a cardiac arrest during hip arthroplasty with a cemented long-stem femoral component. Four patients died in the operating room, and three patients were successfully resuscitated. When the three survivors were eventually discharged from the hospital, they had no known permanent cardiac, pulmonary, or neurological sequelae. Factors that were common to all of the patients were advanced age, osteoporotic bone, a previously undisturbed intramedullary canal, and use of a long-stem femoral component and several batches of methylmethacrylate. Hip arthroplasty with a long-stem femoral component is associated with substantial risk in these patients. Excessive pressurization of cement should be avoided, and invasive hemodynamic monitoring should be used when the described conditions are present.

Bipolar hemiarthroplasty for fracture of the femoral neck.

Controversy in the treatment of displaced femoral neck fractures in the elderly focuses on the use of fixation versus the use of a prosthesis. Beginning in 1980, at The New York Hospital-Cornell Medical Center, it became routine to treat elderly patients for displaced fractures with bipolar hemiarthroplasty. This retrospective study evaluates the morbidity, mortality, and clinical and social functioning of 246 consecutive patients treated with bipolar hemiarthroplasty for Garden III and Garden IV nonpathological fractures. Follow-up ranged from 1 to 6 years. Of the 246 patients with 247 femoral neck fractures, 201 were female and 45 were male; the average age was 78 years. Fourteen patients (5.7%) died during the postoperative hospitalization. Thirty-one patients (13.3%) died within the first year following surgery. Mortality was related to the number of preexisting medical conditions: patients with four or more preexisting conditions had a significantly higher mortality than others (p less than 0.001: chi 2). The overall wound infection rate was 3.2%. There were only two failures (0.9%), both for deep infection, requiring Girdlestone debridement. One patient was revised for infection with successful reimplantation. There were two postoperative dislocations (0.9%), both reduced closed. Only one bipolar (0.4%) required conversion to a total hip replacement for a fractured acetabulum, none for arthritic wear. No radiographic evidence of significant acetabular erosion or protrusion nor femoral component loosening was noted. Clinical results were evaluated using the Hospital for Special Surgery Hip Rating Scale.(ABSTRACT TRUNCATED AT 250 WORDS)

Multicenter trial of Collagraft as bone graft substitute.

Collagraft (Zimmer and Collagen Corporation) consists of a mixture of porous beads composed of 60% hydroxyapatite and 40% tricalcium phosphate ceramic and fibrillar collagen. When mixed with autogenous bone marrow, it serves as an effective bone graft substitute. Since September 1986, this material has been used in a multiclinic prospective trial, randomized against cancellous iliac crest autografts in the treatment of long bone fractures. To date, 267 patients have entered this study with 128 patients receiving cancellous autograft and 139 patients receiving Collagraft. At 6- and 12-month follow-ups, Collagraft appears to function as well as autogenous graft when used in the treatment of acute long bone fractures.