A review of atypical subtrochanteric femoral fractures in Northern Ireland between 2010 and 2014.

The term atypical femoral fractures most commonly occur in the subtrochanteric area. Concerns exist regarding the role of bisphosphonate treatment in their aetiology. Which surgical intervention provides the best outcome remains contentious. We reviewed all atypical subtrochanteric femoral fractures treated in Northern Ireland over 5 years, specifically investigating incidence, prodromal symptoms, association with bisphosphonates and optimal fixation methods. All subtrochanteric fractures treated in the region were identified and reviewed for atypical features. Case notes and imaging were then reviewed for each patient. A total of 364 subtrochanteric femoral fractures were identified during the 5-year study period. Twenty-six of these met the criteria for an atypical fracture (7%). Thirteen patients (50%) had presented with prodromal symptoms prior to complete fracture, six of which had radiological evidence of an incomplete fracture of the lateral cortex. Thirteen patients had a history of bisphosphonate treatment. All were treated operatively, with twenty-five cephalomedullary nails and one dynamic hip screw. Twenty-one patients had follow-up for greater than 2 months, nine of which (42.9%) achieved radiological union with a mean time to union of 297 days. Dynamically locked nails had a higher union rate than statically locked (80% versus 33.3%). Four patients required major revision surgery (15.4%). The quality of reduction was statistically significant in predicting need for revision. Atypical fractures often present with prodromal symptoms. Complete fractures are difficult to successfully manage with longer than expected times to union. Treatment with a dynamically locked, cephalomedullary with a good reduction provided the best results.

The changing face of fractures of the hip in Northern Ireland: a 15-year review.

AIMS: We reviewed all patients who sustained a fracture of the hip and were treated in Northern Ireland over a period of 15 years to identify trends in incidence, the demographics of the patients, the rates of mortality, the configuration of the fracture and the choice of implant. PATIENTS AND METHODS: Since 01 January 2001 data about every fracture of the hip sustained in an adult have been collected centrally in Northern Ireland. All adults with such a fracture between 2000 and 2015 were included in the study. Temporal changes in their demographics, the mode of treatment, and outcomes including mortality were analysed. RESULTS: The incidence of fractures of the hip, in Northern Ireland, rose from 54 in 100 000 in 2000 to 86 in 100 000 in 2015. If these trends continue, we predict this rising to 128 in 100 000 in 2030. We found that these patients are becoming older and increasingly frail, as assessed by the American Association of Anesthesiology grade. Complex extracapsular fractures have become more common since 2009, which may explain the increased use of cephalomedullary nails. Despite increasing frailty, the 30-day and 12-month rates of mortality fell significantly (p = 0.002 and 0.001, respectively). CONCLUSION: Fractures of the hip are becoming more common and more complex in an aging, increasingly frail population. We expect these trends to continue. This will place an increasing economic and clinical strain on healthcare systems. Forward planning is essential to put systems in place that can deal with the increasing demand. Cite this article: Bone Joint J 2017;99-B:1223-31.

Delayed diagnosis of developmental dysplasia of the hip in Northern Ireland: can we do better?

Developmental dysplasia of the hip (DDH) should be diagnosed as early as possible to optimise treatment. The current United Kingdom recommendations for the selective screening of DDH include a clinical examination at birth and at six weeks. In Northern Ireland babies continue to have an assessment by a health visitor at four months of age. As we continue to see late presentations of DDH, beyond one year of age, we hypothesised that a proportion had missed an opportunity for earlier diagnosis. We expect those who presented to our service with Tonnis grade III or IV hips and decreased abduction would have had clinical signs at their earlier assessments. We performed a retrospective review of all patients born in Northern Ireland between 2008 and 2010 who were diagnosed with DDH after their first birthday. There were 75 856 live births during the study period of whom 645 children were treated for DDH (8.5 per 1000). The minimum follow-up of our cohort from birth, to detect late presentation, was four years and six months. Of these, 32 children (33 hips) were diagnosed after their first birthday (0.42 per 1000). With optimum application of our selective screening programme 21 (65.6%) of these children had the potential for an earlier diagnosis, which would have reduced the incidence of late diagnosis to 0.14 per 1000. As we saw a peak in diagnosis between three and five months our findings support the continuation of the four month health visitor check. Our study adds further information to the debate regarding selective versus universal screening.

Does K-wire position in tension band wiring of olecranon fractures affect its complications and removal of metal rate?

BACKGROUND: Despite the recognised complications of migration of wires and soft tissue irritation, tension band wiring (TBW) remains the gold standard for fixation of displaced, minimally comminuted olecranon fractures. There is much variation in placement of the K-wires with current AO guidance stating that each wire should be drilled through the anterior cortex and then backed up by 1 cm. The aim of this study was to examine the effect of K-wire position (intramedullary vs. transcortical) on stability of the construct and significant local complications. METHODS: All patients who underwent TBW for an isolated olecranon fracture in our trauma unit between 1/1/2009 and 31/12/2011 were included in this retrospective study. Mean follow-up was 14 months (range 5-29 months). Data was gathered from medical records and radiographs. The outcome measured was removal of metal due to complications such as wound problems or proximal migration of wires as standard practice within out trauma unit. RESULTS: Sixty-three patients met the inclusion criteria. Forty-seven had an intramedullary compared with 16 with transcortical configuration (ratio 3:1). Nine patients (19%) with intramedullary K-wires required removal of metalwork - seven due to prominent metalwork and two with wound infection. Four patients (25%) with transcortical K-wires required removal of metalwork - three due to prominent metalwork and one with failure of metalwork. There was no significant statistical difference between transcortical and intramedullary K-wire placement with regards to complication rates following tension band wiring of an isolated olecranon fracture requiring removal of metal (Chi squared test with Yates' correction p = 0.89). CONCLUSION: We concluded that we found no difference in complications or metalwork removal rate in the placement of K-wire in tension band wiring for isolated olecranon fracture. We recognise our study was limited by small numbers and is based on the experience of one trauma unit.

Reliability of a modified tissue factor-dependent factor V assay for activated protein C resistant factor Va using a calcium-containing thromboplastin.

The original tissue factor-dependent factor V assay for activated protein C resistant factor Va (Blood 1995; 85: 1704-1711) has been modified to use a calcium containing thromboplastin and to express results as an observed to expected ratio (Obs/Exp.). The latter permits establishing a normal range independent of variations due to differences in reagents. Comparing Obs/Exp ratios with DNA analysis in 72 persons revealed that an Obs/Exp ratio of 0.6 distinguished without overlap normals from heterozygotes for FV R506Q. Three homozygotes had a ratio of < 0.1. Application of this Obs/Exp cut-off ratio of 0.6 to a total of 226 plasma samples tested to date discriminated without overlap between normals and heterozygotes. We conclude that this assay-readily adaptable to any dedicated coagulation laboratory and capable of yielding reliable results in all clinical circumstances in which testing is indicated-can distinguish between normals and heterozygotes for the FV R506Q mutation without the need for confirmatory DNA analysis.

Three-dimensional magnetic resonance imaging evaluation of pediatric tracheobronchial tree.

Magnetic resonance imaging (MRI) of the airway has recently emerged as a diagnostic tool for evaluating tracheobronchial obstruction in pediatric patients. Computer-assisted reconstructions of transaxial images have enabled three-dimensional reconstructions of the airway to be manipulated in any plane and visualized in relation to adjacent anatomical structures. Eight patients in whom magnetic resonance imaging was used to diagnose a variety of airway obstructive lesions are presented. A protocol for the evaluation of pediatric tracheobronchial obstruction is presented, with the role of three dimensionally reconstructed MR imaging emphasized.

The international normalized ratio (INR) for monitoring warfarin therapy: reliability and relation to other monitoring methods.

OBJECTIVE: To enhance understanding of the reliability of the international normalized ratio (INR) for monitoring warfarin therapy and its relation to other monitoring techniques. DESIGN: Prospective cohort study. SETTING: A university hospital. PATIENTS: 79 patients attending an anticoagulation clinic. MEASUREMENTS: International normalized ratios obtained with a portable capillary monitor (Coumatrak) and the following from a simultaneous plasma sample: INRs from prothrombin times done with six thromboplastins, prothrombin-proconvertin (P&P) test activity, specific prothrombin activity, and native prothrombin antigen. RESULTS: Converting to INRs failed to standardize prothrombin time results obtained with high- and low-sensitivity thromboplastins. Coumatrak INRs correlated best with INRs obtained with high-sensitivity thromboplastins. The INR range of 2.0 to 3.0 corresponded to a P&P range of 30% to 13%, a native plasma prothrombin antigen range of 56 to 24 micrograms/mL, and a specific prothrombin activity range of 43% to 21%. CONCLUSIONS: Low-sensitivity thromboplastins may give erroneously high INRs in the upper therapeutic range. Plasma prothrombin times should be done with a high-sensitivity thromboplastin, particularly in patients maintained at the upper limit of the therapeutic range. An INR so obtained correlated well with an INR obtained with a portable capillary blood monitor.

Selective streptokinase infusion: clinical and laboratory correlates.

Selective intra-arterial infusions of streptokinase (SK) were made in 50 arteries of 45 patients with a variety of acute thromboembolic conditions. The most common regimen was 5,000 units of SK/hour for 24 to 48 hours with a simultaneous heparin infusion of 250 to 500 units/hour. Significant lysis occurred in 80% of cases, with 74% of the patients benefiting clinically. Minor bleeding, usually from puncture sites, occurred in 30% of the patients. Major hemorrhages, requiring transfusion or surgery, developed in four patients (8%). No hemorrhagic strokes or fatalities were directly attributable to SK infusion. Coagulation parameters were determined before infusion, 4 and 24 hours after infusion, and every 24 hours thereafter. Significant alterations of coagulation parameters developed promptly, but were not very useful in predicting either clinical response or hemorrhage. Selective intra-arterial infusion of SK is a moderately effective and safe therapeutic technique in acute peripheral arterial thromboembolic disease. A comparison with prior reports suggests that selective low-dose infusion provides a moderate gain in benefit-risk ratio over systemic infusion.

A bleeding disorder due to deficiency of alpha 2-antiplasmin.

A deficiency of alpha 2-antiplasmin has been identified in a female patient with severe and frequent bleeding episodes. Routine coagulation and platelet assays of the patient's plasma were within normal limits. However, abnormally rapid whole blood or dilute plasma clot lysis times and an abnormal FXIII test in which clots were lysed in the presence of urea or saline suggested an abnormal fibrinolytic system. Analysis of alpha 2-antiplasmin levels by radioimmunoassay revealed less than 1.0 microgram/ml alpha 2-antiplasmin. Functional assays indicated an alpha 2-antiplasmin level less than or equal to 10% of normal. Addition of purified alpha 2-antiplasmin to the patient's plasma restored its ability to inhibit plasmin in in vitro assays, and mixtures of patient plasma with normal plasma did not interfere with the antiplasmin activity of the normal plasma. Whereas normal platelets contain 68 ng alpha 2-antiplasmin/10(9) platelets, platelets from the patient contained 30% of the normal level of antigen. Analysis of alpha 2-antiplasmin functional and antigenic levels in the plasma of both parents and four siblings of the propositus provided evidence consistent with an autosomal mechanism of inheritance of alpha 2-antiplasmin deficiency. One sibling appeared to be homozygous and three siblings and the parents were heterozygous for the deficiency. Two heterozygotes had positive bleeding histories. The association of a bleeding disorder with a deficiency of alpha 2-antiplasmin emphasizes that lack of regulation of the fibrinolytic system can result in a hemostatic dysfunction.