The natural history of the hemiarthroplasty for displaced intracapsular femoral neck fractures.

BACKGROUND: Numerous papers have been published on the medium- and long-term results of hemiarthroplasties (HAs) after femoral neck fracture in the elderly. We were not aware of any articles that describe the outcome of HA until the patient dies. METHODS: Between 1975 and 1989, 307 bipolar hemiarthroplasties were performed in 302 consecutive patients with a displaced femoral neck facture. Patients with osteoarthritis of the hip, rheumatoid arthritis (RA), or senile dementia were not included in the study. All patients were followed annually until they died or until they needed a revision operation. RESULTS: The mortality rate was 28% after 1 year, and 63% after 5 years. The last patient who did not need a revision operation died in October 2010. Revision operations for aseptic loosening, protrusion, or both had to be performed in 34 patients (16%). A difference in reoperation rate was observed between patients less than 75 years of age (38%) and those who were older (6%). INTERPRETATION: Apart from age below 75 years, male sex appeared to be predictive of a revision operation. HA is a safe and relatively inexpensive treatment for patients over 75 years of age with a displaced femoral neck fracture.

Complications of distal tibiofibular syndesmotic screw stabilization: analysis of 236 patients.

The objective of the present study was to evaluate our complications of screw stabilization and to formulate recommendations for clinical practice. Using a prospectively collected fracture database, the data from 236 consecutive adult patients were analyzed who had undergone syndesmotic screw stabilization from January 1979 to December 2000 at our level I academic trauma center. We observed 16 complications in 15 patients. The average patient age was 37.5 years. Of the 15 patients, 1 had a Weber B fracture and 14 had a Weber C ankle fracture. These complications included tibiofibular synostosis in 11 patients, screw breakage in 4 patients, and late diastasis in 1 patient. All breakages occurred in Weber C fractures. In particular, the 3.5-mm screws, penetrating both tibial cortices, tended to break. Synostosis was observed in 3% of the Weber B fractures and 5% of the Weber C fractures. Weightbearing in a plaster cast during syndesmotic screw stabilization is a safe postoperative treatment. We suggest that the use of 3.5-mm screws and screws penetrating 2 tibial cortices have a greater risk of breakage. Because of the low complication rate and more difficult treatment of late syndesmotic diastasis, a syndesmotic screw should be placed when in doubt of the indication.

Predictors of functional outcome following femoral neck fractures treated with an arthroplasty: limitations of the Harris hip score.

INTRODUCTION: To study the association between potential prognostic factors and functional outcome at 1 and 5 year follow-up in patients with femoral neck fractures treated with an arthroplasty. To analyze the reliability of the Harris hip score (HHS). MATERIALS AND METHODS: A multicenter analysis which included 252 patients who sustained a femoral neck fracture treated with an arthroplasty. Functional outcome after surgery was assessed using a modified HHS and was evaluated after 1 (HHS1) and 5 (HHS5) years. Several prognostic factors were analyzed and reliability of the HHS was assessed. RESULTS: After 1 year the presence of co-morbidities was a significant (p = 0.002) predictor for a poor functional outcome (mean HHS1 71.8 with co-morbidities, and 80.6 without co-morbidities). After 5 years none of the potential prognostic factors had significant influence on functional outcome. Internal consistency testing of the HHS showed that when pain and function of the HHS were analyzed together, the internal consistency was poor (HHS1 0.38 and HHS5 0.20). The internal consistency of the HHS solely in function (without pain) improved to 0.68 (HHS1) and 0.46 (HHS5). Analyzing the functional aspect exclusively, age and the existence of co-morbidities could be defined as predictors for functional outcome of femoral neck fractures after 1 and 5 years. CONCLUSION: After using the HHS in a modification, age and the existence of pre-operative co-morbidities appeared to be predictors of the functional outcome after 1 and 5 years. The HHS, omitting pain, is a more reliable score to estimate the functional outcome, than HHS analyzing pain and function in one scoring system.

Fractures of the capitellum and trochlea.

BACKGROUND: Recent work has established that apparently isolated fractures of the capitellum are often more complex and involve the lateral epicondyle, trochlea, and posterior aspect of the distal part of the humerus. We assessed the experience with operative stabilization of fractures of the capitellum and trochlea at one level-I trauma center over a twenty-eight-year period. METHODS: Thirty classifiable partial articular fractures involving the capitellum and trochlea were included in the study. Twenty-seven patients were followed for a minimum of twelve months, and fourteen patients returned for long-term follow-up at a median of seventeen years. The early and long-term results were evaluated according to the Broberg and Morrey Functional Rating Index. The long-term results were also evaluated according to the Mayo Elbow Performance Index (MEPI), the American Shoulder and Elbow Surgeons (ASES) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: Eighteen patients (67%) had one or more subsequent surgical procedures, and eight of these patients had the procedure to address surgical complications. Five of the eight patients with complications and ten additional patients underwent routine removal of implants; these fifteen patients included twelve of the fourteen patients in the long-term cohort. In addition to the fracture of the distal part of the humerus, four patients had a dislocation of the elbow; three, a fracture of the olecranon or the proximal part of the ulna; and two, a fracture of the radial head. The median arc of flexion improved from 106 degrees at the time of early follow-up to 119 degrees at the time of long-term follow-up (p < 0.05). In the group of fourteen patients with long-term follow-up, the median Broberg and Morrey score was 93 points at the time of early follow-up and 95 points at the time of late follow-up. The functional results were worse for patients with a Type-3 fracture, as classified with the system of Dubberley et al., than they were for those with a Type-1 fracture. The fourteen patients with long-term follow-up had a median MEPI of 98 points, a median ASES score of 88 points, and a median DASH score of 8 points; nine of the fourteen patients had radiographic signs of arthrosis. CONCLUSIONS: The vast majority of what appear to be capitellar fractures are actually complex fractures of the articular surface involving both the capitellum and the trochlea. More complex fractures have worse functional results; however, the functional results of operative treatment seem to be durable over time.

Nonunion of the femoral neck: possibilities and limitations of the various treatment modalities.

Nowadays in cases of nonunions of the femoral neck, the surgeon is tempted to perform prosthetic replacement of the hip, more so if there is also evidence of avascular necrosis of the head of femur. This provides rapid pain relief and allows early mobilization. However, long-term results of hip arthroplasties, especially in younger people and in the presence of osteopenia, are not always as expected; and a less radical approach is worth considering. The intertrochanteric valgization osteotomy, described by Pauwels, is an excellent alternative for healthy patients up to 65 years of age with a nonunion of the femoral neck. A union rate of 80-90% of the nonunion is described by most authors. Leg length inequality, rotational and angular deformities can be corrected at the same time. During the period 1973-1995, we performed valgization osteotomy according to Pauwels in 66 patients of, 18-72 years old (mean 49.5 years). 24 (37%) of our patients died 4 months to 24 years (mean: 9.5 years) after the operation. Union of the femoral neck was achieved in 58 (88%) of the 66 patients; union of the osteotomy in 65 patients (99%). A good or excellent result was achieved in 62% (23 uneventful and 13 with healed, necrosis/arthrosis without need for further treatment) of our patients. However, the method has its limits. We feel if there is too little bone stock inside the femoral head, a valgization osteotomy does not give good result. The radiographic signs of avascular necrosis in patients over 30 years of age is considered a contraindication for an osteotomy. However our results show that it is worthwhile trying to save the joint of young patients even in case of a segmental collapse. In the race between revascularization and collapse, often revascularization is the winner. We deliberately give nature its chance and don't rely on the result of bleeding from drill holes in the head, nuclear scans and other methods to estimate vascularity. A secondary total hip replacement if necessary because of avascular necrosis or osteoarthritis is considerably postponed; and better milieu for hip replacement can be achieved by the development of sclerotic bone in the subchondral areas of the acetabulum and femoral head. Between 65 and 80 years of age, a total hip replacement is probably the best option for fit patients. We treat fresh femoral neck fractures with a hemiarthroplasty in patients over the biological age of 80 years. Logically the same choice will be made for patients with a nonunion. During the period 1973-1995 we performed hemiarthroplasty (n = 34) in patient with low general condition. Their mean age was 79 years. The average survival in these patients was less than three years and that explains probably the low late complication rate: in this group. Total hip replacement was performed in 37 younger patients with a mean age of 69 years. They were not considered for a valgization osteotomy because of age being over 70 years, severe osteoporosis or a total collapse of the femoral head. In this group, we observed one aseptic cup revision and two extractions of the prosthesis because of a deep infection.

Femoral neck fractures: can physiologic status determine treatment choice?

In patients with displaced femoral neck fractures, meta-analysis data show revision rates of 35% after internal fixation and 16% after hemiarthroplasty. A published physiologic status score management protocol, which selects for either treatment, suggests lower revision rates can be achieved but it has not been confirmed. The physiologic status score included subscores for mobility, accommodation, bone density, cognition, and American Society of Anesthesiologists class. We asked whether treatment selection with the physiologic status score could indeed reduce revision rates compared with meta-analysis data and whether surgical technique influenced results. In a prospective multicenter 2-year followup trial we enrolled 115 patients selected for internal fixation and 109 for hemiarthroplasty, aged 60 to 90 years. Healthier mobile patients underwent internal fixation and patients with a lower physiologic status score had hemiarthroplasty. The 2-year revision rate was 40% after internal fixation (above meta-analysis rate) and 3% after hemiarthroplasty (below meta-analysis rate). After a panel identified and excluded 15 technical failure cases, patients younger than 80 years with a high physiologic status score had a one in four revision rate of internal fixation, whereas older patients had a one in two revision rate. Although the revision rate was indeed low after hemiarthroplasty, treatment choice based on physiologic status does not substantially improve clinical decision making.

Fractures of the femoral neck: a review and personal statement.

EPIDEMIOLOGY: The number of hip fractures will increase enormously in the decades to come as will the cost of treatment of these patients do. In the USA the annual cost has estimated to be nearly $10 billion. Hip fractures, therefore, represent an enormous socio-economic and medical problem and challenge (orthopaedic) surgeons an anaesthetists to find the cheapest and most effective way to treat them. At the same time the search for preventive measures should be continued. Biphosphonates and hip protectors seem to be able to decrease the risk of suffering a hip fracture with 50%. CLASSIFICATION: The first classification of femoral neck fractures, proposed by Abraham Colles, in displaced and non-displaced (impacted) fractures appears to be still the most useful one. The Pauwels classification cannot be applied to the preoperative x-ray, because the fractured leg is always in external rotation. The Garden classification is not reproducible and does not lead us to the right treatment. TREATMENT: Stability and healing chances of impacted fractures depend especially on age and general condition. In patients under 70 years of age without co-morbidity, the secondary instability rate after non-operative treatment is very low: 5%. In elderly people with multiple co-morbidity secondary instability can go up to 80%. These patients are better served with primary operative treatment. Although the majority of surgeons feel good with a strategy of prophylactic internal fixation in all patients, this author pleads for non-operative (early mobilization) treatment of all patients, who are healthy or have only one serious comorbidity. There is consensus about the treatment of displaced fractures in patients under 65 years of age: closed reduction and internal fixation. The best treatment for patients over 80 years of age is prosthetic replacement. In the (large) group of patients between 65 and 80 years of age calendar age is not a reliable guide to the right treatment. There is a growing conviction that the choice between internal fixation and prosthetic replacement in these patients should be made on the basis of the biological age (ASA-score, habitat, the activity level, the need for walking aids and cognitive function). Bone density does not seem to play an important role. If internal fixation is the preferred treatment, the choice of implant is controversial. It is the author's experience that fractures with a steep fracture line (Pauwels 3) should be anatomically reduced and stabilized with a sliding hip screw. The less steep fractures (Pauwels 1 and 2) can be slightly over-reduced in valgus and anteversion, which provides a bony support against shearing forces, and fixed with parallel screws according to the 3-point-fixation principle. The timing of surgery continues to be a controversial subject. From a recent study in our own institution we concluded that no significant association could be found between delay to surgery and the clinical outcomes.However, considering the trends towards less complications and shorter length of hospital stay, early surgery (within 1 day from admission) is likely to be beneficial for hip fracture patients who are able to undergo operation. There is agreement about the use of the cemented arthroplasty. If a hemiarthroplasty is chosen, the bipolar type is to be preferred to the unipolar type. The difference in price between both prostheses is negligible because the overall cost of the treatment have gone up so immensely. Furthermore, a basic advantage of the bipolar system is the relatively small operation, needed for conversion to a total hip replacement, because the stem can stay in place. As to the question hemiarthroplasty or total hip replacement, the discussion has not yet been closed. We studied the natural history of the cemented bipolar hemiarthroplasty by evaluating 307 patients, operated between 1975 and 1989 in our institution. Only 3 patients, who not have been revised, were alive at the end of the observation period (2004). A striking difference was found in the occurrence of late mechanical complications (aseptic loosening and acetabular wear) between patients under 75 years of age (22%) and the older group of patients (6%). As to the patient's overall satisfaction 56% suffered no impairment from their sustained fracture, 36% were slightly impaired. We concluded that the use of the cemented bipolar prosthesis is justified in patients over 75 years of age. Patients between 65 and 75 years of age should either be treated with internal fixation or with a total hip replacement. NONUNION OF THE FEMORAL NECK: Nowadays in cases of nonunions of the femoral neck the surgeon is tempted to perform prosthetic replacement of the hip, the more so if there is also evidence of a disturbed vascularisation of the head. This will provide rapid pain relief and mobilization. However, long-term results of hip arthroplasties, especially in younger people and in presence of bone atrophy, are not always as expected and a less radical approach is worth considering. The intertrochanteric valgization osteotomy, described by Pauwels is an excellent alternative for patients up to 65 years of age with a non-union of the femoral neck. A union rate of 80-90% is described by most authors. Leg length, rotational and angular deformities can be corrected at the same time. Between 65 and 80 years a total hip replacement is probably the best option for fit patients. For elderly patients a cemented bipolar hemiarthroplasty is an adequate treatment.

Observer assessment of femoral neck radiographs after reduction and dynamic hip screw fixation.

INTRODUCTION: It is not known how the described methods of reduction and dynamic hip screw (DHS) fixation of displaced intracapsular femoral neck fractures translate into proper assessment of the postoperative radiographs. At teaching or evaluation sessions in daily practice, frequent discussion arises about postoperative technical assessment. The assessment of correct reduction and DHS fixation using the described methods in the literature may be subject to differences between observers. The aim of this study was to assess the extent of inter- and intraobserver agreement on technique, based on the methods in the literature, in a simulated daily practice setting. MATERIALS AND METHODS: The postoperative anteroposterior (AP) and lateral radiographs of 35 randomly selected patients aged 60-90 years were rated twice, 2 months apart, by six surgical observers from three institutions with similar views on reduction and DHS fixation for this fracture type. The radiographs were of sufficient quality for proper assessment. Criteria for reduction and fixation could be rated as either adequate or inadequate. An adequate rating was assigned if in the observer's opinion, regardless of likely outcome, technical perfection according to the described methods had been achieved. The kappa statistic was calculated as a measure of agreement. RESULTS: Fracture reduction on the AP view approached a good kappa value (0.54). Poor to moderate interobserver agreement was found for fracture reduction on the lateral view and aspects of DHS fixation (kappa 0.10-0.36). Intraobserver agreement was good for five out of six observers for reduction and DHS fixation aspects (kappa 0.51-0.81). CONCLUSION: During routine practice six surgical observers can nearly agree on adequate fracture reduction on the AP view, but do not agree on adequate reduction on the lateral view and adequate DHS fixation on the postoperative radiographs of displaced intracapsular femoral neck fractures.

Long-term results of the Weber operation for chronic ankle instability: 37 patients followed for 20-30 years.

BACKGROUND: The Weber operation is an anatomical reconstruction of the anterior talofibular ligament with the plantaris tendon. Few long-term studies have been published. METHODS: We evaluated 40 ankles in 37 patients (19 women) at an average of 24 years after the procedure. RESULTS: At follow-up, symptoms were present to vary-ing degrees in half of the ankles, but 32 patients were satisfied with the result and approximately two-thirds of the patients had a good or excellent result with the Karlsson and Good scores. Only 3 ankles had secondary arthrotic changes with narrowing (2 patients) or disappearance (1 patient) of the joint space. INTERPRETATION: We conclude that the Weber procedure is a good alternative for treatment of chronic anterolateral ankle instability when a direct anatomical reconstruction is not feasible, or has failed.

Intra-articular fractures of the distal femur: a long-term follow-up study of surgically treated patients.

OBJECTIVE: To analyze the long-term (5-25 years) functional and radiologic results of surgically treated intra-articular fractures of the distal femur. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS AND METHODS: Sixty-seven surgically treated consecutive patients with 67 intra-articular distal femoral fractures were included in this study. All fractures were classified according to the AO classification. There were 36 men and 31 women. The mean age at time of accident was 45 years (range 16-94 years). There were 38 patients with isolated fractures and 29 with multiple fractures. Median hospital stay was 23 days (range 12-330 days). A 1-year follow-up was done in all 67 patients. Thirty-two of these patients were also seen for an additional long-term follow-up visit. Functional results of these 32 patients were graded using the Neer and HSS knee scores. Radiologic results were graded using the Ahlbäck score. Statistical analysis was performed by means of the SPSS data analysis program. RESULTS: At 1-year follow-up in 40 of 65 patients (62%), the fracture was fully healed, in 22 patients (34%) a fixation callus still existed, and 1 patient had a nonunion. In 2 patients, an arthrodesis was performed. The mean knee range of motion was 111 degrees (range 10-145 degrees). After a mean follow-up of 14 years (range 5-25 years), the mean knee range of motion was 118 degrees (range 10-145 degrees). The Neer score showed good to excellent results in 84% of the patients, and the HSS knee score showed good to excellent results in 75% of the patients. Patients with isolated fractures scored significantly better functionally (Neer/HSS 90 points) compared with those with multiple fractures. The Ahlbäck score showed a moderate to severe development of secondary osteoarthritis in 36% of all patients. Seventy-two percent of these patients still scored a good to excellent functional result. Seven patients (10%) had local complications in the form of a deep wound infection. Five of these patients were treated successfully, whereas 2 had a chronic infection that subsequently led to an arthrodesis. CONCLUSION: Surgical treatment of monocondylar and bicondylar femoral fractures shows good long-term results after open reduction and internal fixation. Knee function increases through time, though the range of motion does not increase after 1 year. The presence of secondary osteoarthritis does not mean less favorable functional results in most patients.