Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a seven- to ten-year follow-up report of a prospective randomised controlled trial.

We reviewed the seven- to ten-year results of our previously reported prospective randomised controlled trial comparing total hip replacement and hemiarthroplasty for the treatment of displaced intracapsular fracture of the femoral neck. Of our original study group of 81 patients, 47 were still alive. After a mean follow up of nine years (7 to 10) overall mortality was 32.5% and 51.2% after total hip replacement and hemiarthroplasty, respectively (p = 0.09). At 100 months postoperatively a significantly greater proportion of hemiarthroplasty patients had died (p = 0.026). Three hips dislocated following total hip replacement and none after hemiarthroplasty. In both the total hip replacement and hemiarthroplasty groups a deterioration had occurred in walking distance (p = 0.02 and p < 0.001, respectively). One total hip replacement required revision compared with four hemiarthroplasties which were revised to total hip replacements. All surviving patients with a total hip replacement demonstrated wear of the cemented polyethylene component and all hemiarthroplasties had produced acetabular erosion. There was lower mortality (p = 0.013) and a trend towards superior function in patients with a total hip replacement in the medium term.

Whiplash injury: 30-year follow-up of a single series.

We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain.

Large diameter femoral head uncemented total hip replacement to treat fractured neck of femur.

The aim of this study was to investigate the use of large diameter head THR to treat fractured neck of femur, and to demonstrate if this conferred greater stability. Forty-six independent, mentally alert patients with displaced intracapsular fractures underwent THR. Mean age was 72.1 years. Outcome measures were dislocation, reoperation/revision rate, Oxford hip score (OHS), EuroQol (EQ-5D) and residential status. At mean follow-up (13.5 months) there were no dislocations. Reoperation, revision and infection rate were all 0%. Two patients died (4.3%). Mean pre-injury and postoperative OHS were 12.1 and 17.6, respectively. Mean pre-injury and postoperative EQ-5D index scores were 0.97 and 0.83, respectively. Mean postoperative walking distance was 2.5miles. There were no changes in residential status. This is the first published series using 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur. We have demonstrated that it affords patients excellent stability with no recorded dislocations.

Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial.

BACKGROUND: Hemiarthroplasty and total hip arthroplasty are commonly used to treat displaced intracapsular fractures of the femoral neck, but each has disadvantages and the optimal treatment of these fractures remains controversial. METHODS: In the present prospectively randomized study, eighty-one patients who had been mobile and lived independently before they had sustained a displaced fracture of the femoral neck were randomized to receive either a total hip arthroplasty or a hemiarthroplasty. The mean age of the patients was seventy-five years. Outcome was assessed with use of the Oxford hip score, and final radiographs were assessed. RESULTS: After a mean duration of follow-up of three years, the mean walking distance was 1.17 mi (1.9 km) for the hemiarthroplasty group and 2.23 mi (3.6 km) for the total hip arthroplasty group, and the mean Oxford hip score was 22.3 for the hemiarthroplasty group and 18.8 for the total hip arthroplasty group. Patients in the total hip arthroplasty group walked farther (p=0.039) and had a lower (better) Oxford hip score (p=0.033) than those in the hemiarthroplasty group. Twenty of thirty-two living patients in the hemiarthroplasty group had radiographic evidence of acetabular erosion at the time of the final follow-up. None of the hips in the hemiarthroplasty group dislocated, whereas three hips in the total hip arthroplasty group dislocated. In the hemiarthroplasty group, two hips were revised to total hip arthroplasty and three additional hips had acetabular erosion severe enough to indicate revision. In the total hip arthroplasty group, one hip was revised because of subsidence of the femoral component. CONCLUSIONS: Total hip arthroplasty conferred superior short-term clinical results and fewer complications when compared with hemiarthroplasty in this prospectively randomized study of mobile, independent patients who had sustained a displaced fracture of the femoral neck.

Fractures of the tuberosity of the calcaneus.

We describe 24 fractures of the tuberosity of the calcaneus in 22 patients. Three were similar to the type of avulsion fracture which has been well-defined but the remainder represent a group which has been unrecognised previously. Using CT and operative findings we have defined the different patterns of fracture of the calcaneal tuberosity. Ten fractures extended into the subtalar joint, but did not fit the pattern of the common intra-articular fracture as described classically. We have defined a new pattern which consists of a fracture of the medial calcaneal process with a further fracture which separates the upper part of the tuberosity in the semicoronal plane. Non-operative treatment of displaced fractures resulted in a mis-shapen heel and a poor functional outcome. Open reduction and internal fixation with either a plate or compression screw did not give satisfactory fixation. We prefer to use an oblique lateral tension-band wire. This technique gave excellent fixation and we recommend it for the treatment of displaced fractures of the tuberosity of the calcaneus.

Displaced intracapsular neck of femur fractures in mobile independent patients: total hip replacement or hemiarthroplasty?

The aim of this study was to compare the outcome of total hip replacement (THR) with hemiarthroplasty in mobile and socially independent patients with displaced intracapsular fractured neck of femur. Thirty-two patients who had been treated by THR were reviewed after a mean of 3.7 years and compared with 42 patients who had been treated by hemiarthroplasty who were reviewed at 3.9 years. At follow-up none of the THRs had required revision whereas 38% of the hemiarthroplasties had required conversion to THR. Six percent of THRs had dislocated. The modified Harris Hip score rated 86% of THRs as 'good' or 'excellent,' whereas only 12% of the remaining hemiarthroplasties achieved a similar rating. Seventy-seven percent of the patients who had received a THR estimated that they could walk more than a mile compared to 27% of the remaining hemiarthroplasties. THR gave a vastly superior functional outcome compared to hemiarthroplasty in this group of patients.

Effects of CSF-1 on cholesterol accumulation and efflux by macrophages.

To assess whether human monocyte-specific colony-stimulating factor (CSF-1) might influence atherogenesis, CSF-1-induced macrophage responses that might contribute to enhanced clearance of low-density lipoprotein (LDL) or modified LDL were investigated. Careful account was made of cell preservation and increases in cell volume and protein (representing increased cell surface area, and thus endocytically active membrane) during culture with CSF-1. This permitted distinction between selective and nonspecific effects of CSF-1, the latter paralleling increases in cellular mass and volume. CSF-1 enhanced mouse peritoneal macrophage survival in vitro during exposure to lipoprotein-deficient serum with or without native LDL or acetylated LDL (Ac-LDL), as judged by maintenance of cellular DNA and cell numbers. In the presence of copper-oxidized LDL (Ox-LDL), such effects were very slight. In all conditions, CSF-1 increased cellular protein content. CSF-1 increased the uptake of both Ac-LDL and Ox-LDL calculated per culture, but this was entirely explicable by the increased cell protein, indicating that there was no selective enhancement of scavenger receptor or other routes for uptake of the modified LDLs. Similarly, CSF-1 also increased the accumulation of cholesterol and its esters nonspecifically. CSF-1 did have a marked and specific effect on the composition of cholesterol esters, decreasing the proportion of polyunsaturated esters relative to monounsaturated and saturated esters. Finally, cholesterol efflux induced by apolipoprotein A1 from Ac-LDL-loaded macrophages was not influenced by CSF-1. Thus, the enhanced macrophage catabolism of modified LDLs by CSF-1 is part of a nonspecific action on the cells but could contribute to a reduction in circulating cholesterol, observed in some situations of CSF-1 presentation in humans.

Soft-tissue injuries of the cervical spine. 15-year follow-up.

Forty patients with a whiplash injury who had been reviewed previously 2 and 10 years after injury were assessed again after a mean of 15.5 years by physical examination, pain and psychometric testing. Twenty-eight (70%) continued to complain of symptoms referable to the original accident. Neck pain was the commonest, but low-back pain was present in half. Women and older patients had a worse outcome. Radiating pain was more common in those with severe symptoms. Evidence of psychological disturbance was seen in 52% of patients with symptoms. Between 10 and 15 years after the accident 18% of the patients had improved whereas 28% had deteriorated.

Authors: who contributes what?

In this issue (see pages 877 to 882) Dr. H. Dele Davies and associates examine how a sample of pediatric department chairs and faculty deans' offices perceive the involvement of faculty members in medical research. Their findings point to the confusion that surrounds the question of authorship in collaborative research. Dr. Drummond Rennie, deputy editor of the Journal of the American Medical Association, has proposed that a complete and descriptive list of "contributors" replace author lists and acknowledgements. Slight modifications to the International Committee of Medical Journal Editors guidelines on authorship retain the designation "author" and the use of acknowledgements but encourage the explicit description of each investigator's contribution. Researchers and editors should continue to explore ways to ensure that contributions to published research are clearly and honestly identified.

Exercise stimulus increases ventilation from maximal to supramaximal intensity.

This study investigated the influence of an exercise stimulus on pulmonary ventilation (VE) during severe levels of exercise in a group of ten athletes. The altered ventilation was assessed in relation to its effect on blood gas status, in particular to the incidence and severity of exercise induced hypoxaemia. Direct measurements of arterial blood were made at rest and during the last 15 s of two intense periods of cycling; once at an intensity found to elicit maximal oxygen uptake (VO2max; MAX) and once at an intensity established to require 115% of VO2max (SMAX). Oxygen uptake (VO2) and ventilatory markers were continually recorded during the exercise and respiratory flow-volume loops were measured at rest and during the final 30 s of each minute for both exercise intensities. When compared to MAX exercise, the subjects had higher ventilation and partial pressure of arterial oxygen (PaO2) during the SMAX intensity. Regression analysis for both conditions indicated the levels of PaO2 and oxygen saturation of arterial blood (SaO2) were positively correlated with relative levels of ventilation during exercise. It was apparent that mechanical constraints to ventilate further were not present during the MAX test since the subjects were able to elevate VE during SMAX and attenuate the level of hypoxaemia. This was also confirmed by analysis of the flow volume recordings. These data support the conclusions firstly, that overwhelming mechanical constraints on VE were not present during the MAX exercise, secondly, the subjects exhibiting the most severe hypoxaemia had no consistent relationship with any measure of expiratory flow limitation, and thirdly, ventilatory patterns during intense exercise are strong predictors of blood gas status.

Needs assessment for reducing infant mortality in Baltimore City: the Healthy Start Program.

Needs assessments are essential for policy formulation and the appropriate design of intervention programs. Recent nationwide data show that among large metropolitan areas of the United States, Baltimore has one of the highest infant mortality rates and ranks in the worst top 10 for blacks and the top 5 for whites for most indicators of poor pregnancy outcome. In this paper, we present the methods and results of a needs assessment that used multiple sources of routinely collected data and was conducted for the purpose of identifying intervention factors contributing to infant mortality in Baltimore City. This needs assessment was used by the Baltimore City Health Department to successfully secure funding for the federal Healthy Start Infant Mortality Prevention Initiative. We present the results of the analyses, along with some of the proposed interventions that resulted from the needs assessment. We also discuss the limitations of this type of needs assessment as well as suggestions for future needs assessments for the design of interventions to improve perinatal health.