Classification of subtrochanteric femoral fractures.

A review of the literature identified 15 different classification methods for subtrochanteric femoral fractures. Only eight of those classifications defined the area of bone, which constituted a subtrochanteric fracture. The actual length of femur defined as the subtrochanteric zone varied from 3 cm up to the level of the femoral isthmus. There was no agreement between the different classifications regarding the proximal and distal border or for those fractures, which traverse anatomical boundaries. In the various classifications, fractures were subdivided into 2-15 subgroups. The majority of the identified studies were unable to find the classifications useful in either determining treatment or predicting the outcome after treatment. We subdivided subtrochanteric fractures into three types based on the degree of fracture comminution. We examined the inter- and intra-observer agreement of our recommended classification. One orthopaedic consultant, one specialist hip fracture surgeon, two trainee registrar orthopaedic surgeons and one specialty trainee in orthopaedics, on two different occasions, 8 weeks apart, independently classified the radiographs of 20 patients with a subtrochanteric fracture. The mean kappa value for inter- and intra-observer variation was 0.71 and 0.79, respectively, with both showing substantial agreement and, therefore, this simpler classification is recommended. Based on the review of previous classification methods, we also recommend that the subtrochanteric zone be defined as the one in which the fracture line crossing the femur is predominantly within the area of bone extending 5 cm below the lower border of the lesser trochanter.

Avascular necrosis after internal fixation of intracapsular hip fractures; a study of the outcome for 1023 patients.

We prospectively studied 1023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using contemporary methods. The overall incidence of avascular necrosis (AVN) was 6.6%. AVN was less common for undisplaced (4.0%) than for displaced fractures (9.5%) and in men (4.9%) than women (11.4%) who had a displaced fracture. The incidence of AVN for those aged less than 60 years and who sustained a displaced fracture was 20.6%, compared to 12.5% for those aged 60-80 years and 2.5% for those aged more than 80 years. Our study showed an increased risk of AVN with younger age and in females with a displaced fracture. We found no association between the incidence of AVN and the interval between injury to surgery.

A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children.

We performed a systematic review of early versus delayed treatment for type III Gartland supracondylar humeral fractures in children. We identified five non-randomised retrospective studies that fulfilled our criteria. We performed the analysis on 396 patients who sustained a type III supracondylar humeral fracture of which 243 (61.4%) belonged to the early treatment group and 153 (38.6%) belonged to the delayed treatment group. The planned treatment was closed reduction and percutaneous pin fixation. We found that failure of closed reduction and conversion to open reduction was significantly higher in the delayed treatment group (22.9%) as compared with the early treatment group (11.1%). Our study provides evidence that type III supracondylar humeral fractures in children should be treated early within 12h of injury.

Fluoroscopy and Paget's disease of the breast.

A case report concerning a 36-year-old woman having developed Paget's disease of the breast subsequent to multiple fluoroscopies as a child for the investigation of Fallot's anomaly/pulmonary atresia is presented. This case is discussed with a brief review of the relevant literature regarding current theories as to the pathogenesis of Paget's disease of the breast, ionizing radiation and its role in dysplastic breast disease and their possible interrelation.

Early growth restriction, membrane phospholipid fatty acid composition, and insulin sensitivity.

An animal model of protein restriction during pregnancy and lactation with subsequent dietary fatty acid manipulation was used to investigate the association between poor early growth, defective unsaturated fatty acid handling, and later disease. Both control and early growth-restricted animals fed a diet rich in saturated fatty acids showed a doubling of the plasma insulin levels as well as a reduced degree of unsaturation in liver and skeletal muscle membrane phospholipids compared with animals fed diets rich in unsaturated fatty acids. The skeletal muscle of early growth-restricted animals weaned onto a saturated fat diet had reduced proportions of 22:6n-3 and increased proportions of 18:1n-9. This reduction in 22:6n-3 is similar to that observed in Pima Indians, a population with a high prevalence of type 2 diabetes.

The effect of insulin on delta5 desaturation in hepG2 human hepatoma cells and L6 rat muscle myoblasts.

In humans there is a correlation between the ratio of arachidonic acid (20:4n-6) to cis 8,11,14 eicosatrienoic acid (20:3n-6) in skeletal muscle phospholipids and insulin sensitivity. This has been interpreted as indicating a link between the activity of the delta5 desaturase enzyme and muscle insulin sensitivity. The present study addressed the possibility that insulin regulates delta5 desaturase activity using L6 rat myoblasts and hepG2 human hepatoma cells. Both cell lines responded to insulin by increasing the amount of D-[U-14C] glucose incorporated into glycogen. In L6 cells, insulin stimulated cis 8,11,14 eicosatrienoic acid uptake and arachidonic acid production but had no effect on the percentage conversion of cis 8,11,14 eicosatrienoic acid to arachidonic acid. In hepG2 cells, insulin had no effect on cis 8,11,14 eicosatrienoic acid uptake or arachidonic acid production. These results suggest that insulin has no direct effect on delta5 desaturase activity in the liver but can alter arachidonic acid production in muscle by altering substrate availability.

Maternal low protein diet in rats programmes fatty acid desaturase activities in the offspring.

Numerous studies show an association between poor fetal growth and adult insulin resistance. Recent studies have shown relation between the long chain polyunsaturated fatty acid composition of skeletal muscle membranes and insulin sensitivity. More detailed analysis has indicated that the activity of delta5 desaturase is inversely correlated to insulin resistance. The amount of docosahexaenoic acid (C22:6n3) is also thought to play a part in determining insulin sensitivity. The purpose of this study was to test the hypothesis that early growth retardation in the rat, as a result of maternal protein restriction, would lead to alterations in desaturase activities similar to those observed in human insulin resistance. There were no differences in phospholipid fatty acid composition in liver or muscle from control and low protein rats. In both muscle and liver the ratio of docosahexaenoic acid to docosapentaenoic acid was, however, reduced in low protein offspring. Direct measurement of delta5 desaturase activity in hepatic microsomes showed a reduction (p < 0.03) in the low protein offspring which was negatively correlated (r = -0.855) with fasting plasma insulin. No correlation was observed in controls. These results show that it is possible to programme the activity of key enzymes involved in the desaturation of long chain polyunsaturated fatty acids. This is possibly a mechanism linking fetal growth retardation to insulin resistance.