Trochanteric fractures. Mobility, complications, and mortality in 607 cases treated with the sliding-screw technique.

Six hundred seven trochanteric fractures (563 patients) were treated with a sliding-screw technique and followed clinically and roentgenographically for at least one year. Of 351 patients admitted from their homes, 209 (60%) were discharged to their homes after an average of 18 days in the hospital. During the first year another 61 (17%) patients returned home after rehabilitation in a geriatric ward. Of 446 patients walking without support or with one cane before surgery, 360 (80%) had regained the same mobility after one year. The one-year mortality rate was 18%, while the ten-year rate was 74%. Compared with a control cohort, the mortality rate was increased during the first two years after fracture. The increase in mortality was influenced by advanced age, admission from long-term care institutions, male gender, and ambulatory or nonambulatory status before surgery. Forty-five (7.4%) were reoperated, 17 because of technical complications, three because of infection, and three because of nonunion. No further nonunions occurred. The deep infection rate was nine of 339 (2.7%) before and two of 268 (0.8%) after the introduction of antibiotic prophylaxis. Thromboembolic complications decreased from 4.1% to 1.2% after the introduction of dextran 70 as thromboembolic prophylaxis.

Trochanteric fractures. Influence of reduction and implant position on impaction and complications.

A review of roentgenograms and charts was made of 532 trochanteric fractures treated by the sliding-screw technique. According to Evans' modified classification, 65% of the fractures were unstable. There was no breakage or bending of implants. Twenty (3.8%) reoperations were performed because of technical complications or nonunion. The Singh index revealed more unstable fractures and technical complications in hips with Grades 1-3 than in hips with Grades 4-6. Reoperation was more frequent if the screw tip was within 8 mm from the subchondral line in the superolateral quadrant or in the anteroproximal quadrant than if the screw ended farther from the subchondral line. Fifty-five (10.8%) of the lag screws migrated 2 mm or more. Postoperatively, the neck-shaft angle decreased more in unstable fractures than in stable fractures. The decrease in neck-shaft angle was less when the proximal fragment impinged medially on the shaft fragment. Unstable fractures with this type of reduction also impacted less than hips with anatomic reduction or medial reduction of the shaft fragment. Weight bearing did not significantly influence the degree of impaction.

Redisplacement of nailed femoral neck fractures. 4-year follow-up of 110 cases.

In 110 femoral neck fractures, we measured the articulotrochanteric distance and the anteroposterior position of the femoral head, preoperatively, postoperatively, and at a minimum follow-up of 2 years. In displaced fractures the size of the displacement could not be used to predict future incidence of fracture redisplacement or femoral head necrosis.

Articulotrochanteric distance in slipped capital femoral epiphysis.

The difference in altitude between the proximal limit of the femoral head and the tip of the greater trochanter--the articulotrochanteric distance (ATD)--was recorded in 312 patients with slipped capital femoral epiphysis and compared with that in normal hips. The ATD was markedly reduced after severe slipping, independent of the method of treatment. In mild or moderate slippings, the ATD differed with the method of treatment. The shortest ATD was seen after osteosynthesis with AO screws. Nonoperative treatment and osteosynthesis with the Johansson nail or Nyström pin caused a slight reduction of the ATD, while no reduction was seen after hook-pinning. These differences probably reflect various degrees of damage to the subcapital growth plate, which may result in leg length difference and abduction insufficiency.

Hip fractures in northern Sweden 1973-1984. A comparison of rural and urban populations.

The hip-fracture incidence in persons aged 50 years and older in the two northernmost counties of Sweden was studied during three periods between 1973 and 1984. The mean age rose from 75 to 78 years, and the annual number of fractures increased from 511 to 754. Half of this increase could be attributed to demographic aging. For persons 80 years and older, the fracture incidence in 1983/84 was higher (P less than 0.01) than the fracture incidence in 1973/74. The women/men ratio was approximately 2:1 during the survey, while the ratio cervical/trochanteric fracture type changed from 1.7:1 to 1.8:1. The crude fracture incidence rate rose from 4.4 to 5.8 fractures per 1,000 women 50 years and older; the corresponding figures for men were 2.3 and 3.4. Comparison of a rural mountain population with an urban population revealed a lower age-adjusted hip-fracture incidence rate in the rural area during the final part of the study (P less than 0.001). In the rural population, there was no change in age-specific incidence during the survey, while in the urban area the age-specific incidence in person 75 years and older was higher in 1983/84 compared with 1973/74.

Chronic anterolateral instability of the knee. A roentgen stereophotogrammetric evaluation.

The rotatory stability of the knee was investigated in 20 patients with a previous tear of the ACL. The three-dimensional movements of the tibia during the testing procedure were registered using roentgen stereophotogrammetric analysis. Changes of the tibial movements between an intermediate, an anterior, or a posterior tibial position were registered using tibial tractions in combination with a simultaneous external or internal rotatory torque. At 20 degrees of flexion the internal rotatory laxity was increased on the injured side. The external rotatory laxity did not significantly differ between the two sides. With anterior traction, the internal rotatory laxity increased on both the injured and the normal sides and became almost equal. The external rotatory laxity manifested a decrease which was most pronounced on the injured side. With posterior traction, the rotatory laxities decreased and did not significantly differ between the two sides. Analysis of the simultaneously occurring translations of the tibial plateau disclosed abnormal displacements of both the medial and the lateral tibial condyles on the injured side.

Stability of femoral neck fractures. A postoperative roentgen stereophotogrammetric analysis.

Using roentgen stereophotogrammetric analysis, the postoperative stability of femoral neck fractures was measured in 16 patients. During the first day after internal fixation, before weight bearing, the center of the femoral head moved on an average 1.5 mm (total translation) in six undisplaced fractures and 3.7 mm in 10 displaced fractures, which was about one third of the fracture movement during the first postoperative month. Three undisplaced fractures displayed a rotatory instability, mainly after weight bearing had begun. Five of the displaced fractures showed maximal rotatory displacement during the first postoperative day. The recorded fracture movements before weight bearing may question the rationale of peroperative mechanical compression.

Chronic lateral instability of the ankle. Roentgen stereophotogrammetry of talar position.

Using roentgen stereophotogrammetric analysis (RSA), we investigated the talar mobility in 54 ankles during the anterior drawer and adduction tests. Talar tilt was increased in ankles with unilateral symptoms of chronic lateral instability. No other difference in talar tilt and anterior drawer sign was noted comparing ankles with and without symptoms. We conclude that mechanical tests cannot always verify the diagnosis "chronic lateral instability of the ankle".

Poor fixation of the Mittelmeier hip prosthesis. A clinical, radiographic, and scintimetric evaluation.

We have evaluated 30 Mittelmeier hips on an average 3.3 years after the operation. Seven hips had been revised because of severe pain and mechanical loosening and one because of fracture of the threaded ceramic cup. Only five of the remaining 22 hips were asymptomatic. There was radiographic migration of the acetabular and femoral components in more than one third of the hips and increased scintimetric values around the femoral component in all but two hips. Unfavorable design of the Mittelmeier prosthesis may be an important etiologic factor contributing to poor component fixation and inferior clinical results.

Fracture of the lower extremity after total hip replacement.

The incidence of ipsilateral fracture of the lower extremity after total hip replacement (THR) was evaluated in 1442 THRs performed between 1968 and 1983. Twenty-two fractures had occurred, of which 14 were femoral. Twelve of the femoral fractures occurred in women and two in men. The accumulated postoperative risk of femoral fracture during an observation period of 15 years was 25.3 per 1000. Short femoral stems were associated with proximal femoral fractures and long stems with more distal femoral fractures. No specific preoperative diagnosis such as arthrosis, rheumatoid arthritis, or femoral neck fracture was associated with significantly increased incidence of postoperative fractures.

Fixation of unstable trochanteric hip fractures. A cadaver study comparing three different devices.

A four-fragment trochanteric fracture was produced in 24 human cadaver femora. After reduction to anatomic position, the fractures were stabilized by either a Jewett 135 degree nail-plate, a 135 degree Nolok sliding screw-plate without a key, or a 140 degree Hansson pin-plate with an additional trochanteric plate. Using a hip-force simulator, the preparations were subjected to 10,000 loading cycles simulating partial weight bearing, followed by another 10,000 cycles with full weight bearing, while measuring the elastic and permanent fracture displacements. Failure occurred in 3/8 of the Jewett stabilized fractures and in 1/8 each of the Nolok and Hansson stabilized specimens. Each failure was preceded by an increase in elastic tilt and rotation followed by a permanent rotation after which failure occurred as varus angulation of the fracture. Further, two Jewett nails, one Nolok screw, and three Hansson pins showed bending. Due to the controlled telescopic action in the Nolok and Hansson dynamic devices, the resistance to fatigue when subjected to repetitive loadings was increased and thereby a better overall result was achieved when compared with the rigid Jewett nail-plate. To maintain the dynamic function, the strength of the dynamic screw-pin must be sufficient to withstand physiologic loadings without bending; otherwise, the telescopic action will be obstructed.

Three-dimensional instability of the anterior cruciate deficient knee.

Using roentgen stereophotogrammetry we have recorded the three-dimensional movements of the knee during an anteroposterior laxity test in 36 patients with torn anterior cruciate ligaments and in three cadaver knees. At 30 degrees of knee flexion and before loads were applied the tibia occupied a more laterally rotated position if the anterior cruciate ligament had been injured. When the tibia was pulled anteriorly knees with cruciate deficiency rotated more laterally and were more abducted than normal knees. Posterior traction induced lateral rotation in the injured knee and medial rotation in the intact one. Precise knowledge of the three-dimensional instability of the anterior cruciate deficient knee may be important when the laxity is evaluated only in relation to one of the three cardinal axes.

Displacement in femoral neck fractures. A numerical analysis of 200 fractures.

We measured the proximal-distal and anterior-posterior displacement of the femoral head in 200 femoral neck fractures. The numerical data were compared with the Garden classification. The average displacement of the Stages I and II fractures were almost equal. Moreover, the displacement of the Stage III fractures did not differ from the displacement of the Stage IV fractures. The Garden Stages I and II fractures displayed a more posterior position of the femoral head than did the normal hips. The femoral heads of Stages III and IV were situated more posterodistally than those of the Stages I and II fractures. Classification of femoral neck fractures into two groups without (Stages I and II) and with (Stages III and IV) proximal displacement is probably sufficient for clinical use.

Stability of osteosynthesis in trochanteric fractures. Comparison of three fixation devices in cadavers.

Stable trochanteric fractures were produced in 12 pairs of human cadaver femora, which were fixed by either a 135 degree Jewett nail plate, a 135 degree NoLok sliding screw/plate, or a 140 degree Hansson pin/plate. The bone-implant preparations were then subjected to 20,000 load cycles simulating full weight bearing, measuring the elastic and permanent fracture displacement. In each case, elastic displacement occurred during loading. For the Jewett-stabilized fractures, a steady increased elastic displacement, as well as permanent displacement, was seen throughout the test, causing 2/8 failures when the implant penetrated the femoral head. In the NoLok- and Hansson-stabilized fractures, there were no failures, both giving better overall stability than the Jewett device with sufficient fracture stability throughout the test.

Correction of deformity after femoral birth fracture. 16-year follow-up.

At birth a girl sustained a displaced femoral fracture that healed with considerable shortening and angulation. The correction by growth of the deformity was followed radiographically during the entire 16-year growth period.

Acute confusional states in elderly patients treated for femoral neck fracture.

The aims of this study were to estimate the incidence of acute confusional state (ACS), its predisposing factors and consequences in 111 consecutive patients operated for fractured neck of the femur. The incidence of ACS was 61 percent and the predicting factors were old age and dementia. Drugs with anticholinergic effect, depression, and previous stroke were factors that seemed to be associated with the development of ACS. Ninety-two percent of the patients who had severe perioperative blood pressure drops developed ACS. The consequences of ACS were prolonged ward-stay at the orthopedic department, a greater need for long-term care after discharge, and poor walking ability at discharge and six months after surgery. The confused patients also had more complications, such as urinary problems, feeding problems and decubital ulcers, as compared with the nonconfused patients.

The calcar femorale as a landmark in hip physiolysis.

The position of the femoral head in relation to the calcar femorale was analyzed from 120 radiographs of normal hips. A constant relationship was found, providing a method of calculating the normal position of the femoral head. The method was tested in 56 cases with physiolysis of the hip and was found to be useful in determining the degree of slipping in both adolescents and adults.

Active knee motion after cruciate ligament rupture. Stereoradiography.

In 10 patients with an old injury of the anterior cruciate ligament, the three-dimensional movements of the knee joint were studied when the patients flexed their knees. Tibial motions were recorded using roentgen stereophotogrammetric analysis. Internal rotation and adduction of the tibia were reduced in the injured knees when compared with the intact knees; during flexion of the knee joint, the tibial intercondylar eminence occupied a more lateral and posterior position on the injured side. Our results may indicate that the knee joint is continuously exposed to abnormal stresses when the anterior cruciate ligament is torn.

Bilaterality in slipped upper femoral epiphysis.

The frequency of slipping and osteoarthritis of the contralateral hip was recorded in 260 patients with slipped upper femoral epiphysis between 1910 and 1960. Twenty-three of these patients (9%) had primary bilateral slipping, 32 (12%) had a contralateral slip diagnosed later during adolescence and a further 104 (40%) had signs of contralateral slipping at follow-up 16 to 66 years later, giving a total of 159 cases (61%) with bilateral slips. Of the 104 slippings diagnosed at follow-up, 25% showed osteoarthritis. It is concluded that, with a slipped epiphysis, prophylactic contralateral pinning should be performed to avoid slipping and to reduce the risk of osteoarthritis.