Mortality following hip fracture surgery in patients with recent myocardial infarction.

INTRODUCTION: In an elective setting, surgery is best avoided for at least 6 months following myocardial infarction. However, in the presence of a femoral neck fracture, this would most probably lead to significant complications in relation to prolonged immobilisation. There is no published mortality data for patients undergoing surgery for hip fracture following a recent myocardial infarction. The aim of this retrospective study was to assess the mortality of hip fracture patients with a recent myocardial infarction that have undergone surgery at our institution. PATIENTS AND METHODS: Between January 2003 and October 2005, 2270 patients were admitted to our unit with a proximal femoral fracture. Of these, 11 patients were found to have a recent myocardial infarction. RESULTS: Of these 11 patients, 8 were female. The average age was 78.2 years (range, 59-90 years). Average delay from the time of infarction to operation was 11.2 days (range, 3-23 days). Mortality at 1 and 6 months was 45.4% and 63.5%, respectively. DISCUSSION: This is much higher than the overall reported mortality following proximal femur fracture. This information may be useful when planning future peri-operative care and discussing overall prognosis with patients and their relatives.

Head-at-risk signs in Legg-Calvé-Perthes disease: poor inter- and intra-observer reliability.

BACKGROUND: The head-at-risk signs are used as prognostic indicators in Legg-Calvé-Perthes disease. These signs have been assessed only once regarding inter-observer reliability, however. Intra-observer reliability seems not to have been studied to date. METHOD: 76 anteroposterior pelvic radiographs of unilateral Legg-Calvé-Perthes disease were assessed by 5 observers on 2 occasions, in order to assess the inter- and intra-observer reliability in identifying head-at-risk signs. The observers included 1 consultant pediatric orthopaedic surgeon, 1 consultant radiologist, 2 specialist registrars and 1 senior house officer. Inter- and intra-observer reliabilities were assessed using the kappa coefficient. RESULTS: The intra-observer reliability was good for lateral subluxation and metaphyseal cystic changes, moderate for lateral calcification, and fair for Gage's sign and horizontal growth plate. The inter-observer reliability was moderate for lateral subluxation, fair for lateral calcification and metaphyseal cystic changes, and slight for Gage's sign and horizontal growth plate. INTERPRETATION: There was considerable variation in the diagnosis of the head-at-risk signs between observers. This makes the classification difficult to use in clinical practice.

Patellar tendon or four-strand hamstring? A systematic review of autografts for anterior cruciate ligament reconstruction.

The choice of graft for anterior cruciate ligament reconstruction remains controversial. A systematic review was performed to compare bone-patella tendon-bone and four-strand hamstring grafts. Medline (1966 onwards), EMBASE (1980 onwards) and the Cochrane database were searched retrieving 6312 possible articles, but only 6 studies fulfilled all the inclusion criteria. To be included, the study had to be prospective, randomised or quasi-randomised, comparing 4SHS and central third BPTB autografts, inserted using an arthroscopically assisted technique and have a minimum 2-year follow-up for all patients. These studies recruited 526 patients, and 475 were followed for at least 2 years with 235 patients receiving a bone-patella tendon-bone graft and 240 receiving a four-strand hamstring graft. Overall, there was a greater chance of extension loss (p=0.007) and a trend towards increased patellofemoral joint pain (p=0.09) with a patella tendon graft. With a four-strand hamstring graft, there is a greater loss of hamstring power (p=0.008) and a trend towards an increased chance of a pivot shift >1 (p=0.12). There was no difference between the two groups in terms of Lachman testing, chance of returning to the same level of sport, clinical knee scores, graft ruptures or other complications.

A comparison between forefoot plaster and wooden soled shoes following Mitchell's osteotomy for hallux valgus.

Between 1 October 1997 and 1 November 1998, 43 patients (59 feet) were treated with a standard Mitchell's osteotomy for hallux valgus. Of these, 26 patients (36 feet) were treated postoperatively in a forefoot plaster. The other 17 patients (23 feet) were treated with a wooden soled shoe. There was no significant difference between the 2 groups for age, indication for surgery, pre-operative deformity or grade of the operating surgeon. There was no significant difference in the mean time immobilised, mean time to union or complications. The patients were interviewed by telephone after a mean follow-up of 9.4 months. There was no significant difference in results between the 2 groups. This suggests that a forefoot plaster following Mitchell's osteotomy is unnecessary. Postoperative mobilisation in a wooden soled shoe can be used as an alternative.

Minimum 5-year follow-up and radiologic analysis of the all-polyethylene tibial component of the Kinemax Plus system.

All-polyethylene tibial components remain controversial. We report a series of 249 cemented Kinemax Plus total knee arthroplasties using an all-polyethylene tibial component. After a minimum of 5 years, the median Knee Society pain, Knee Society function, and Hospital for Special Surgery Scores were 89, 60, and 83.5 with 86% good or excellent results. The cumulative survival rate was 94.5% at 7 years. Of tibial components, 38% had a radiolucent line, but only 1% had significant radiolucencies. The presence of a radiolucent line did not affect Knee Society or Hospital for Special Surgery scores adversely. This series is comparable to other series using either an all-polyethylene or a metal-backed tibial component. There currently is no good evidence that the experimentally superior metal-backed tibial components offer any advantage in practice.