A multicentre, prospective, randomised comparison of the sliding hip screw with the Medoff sliding screw and side plate for unstable intertrochanteric hip fractures.

OBJECTIVE: This study aimed to compare the dynamic hip screw (DHS) and Medoff sliding plate (MSP) for unstable intertrochanteric hip fractures. DESIGN: A randomised, prospective trial design was used. SETTING: The study was undertaken in two level-1 trauma centres and one community hospital. PATIENTS/PARTICIPANTS: A total of 163 patients with unstable intertrochanteric hip fractures (Orthopaedic Trauma Association (OTA) 31-A2) were randomised to DHS or MSP. Inclusion and exclusion criteria were designed to focus on isolated unstable intertrochanteric hip fractures in ambulatory patients. INTERVENTION: Randomisation was performed intra-operatively, after placement of a 135° guide wire. Follow-up assessments were performed at regular intervals for a minimum of 6 months. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was re-operation rate. The secondary outcome was patient function, evaluated using a validated outcome measure, the Hip Fracture Functional Recovery Score. Tertiary outcomes included: mortality, hospital stay, quality of reduction and malunion rate. RESULTS: A total of 86 patients were randomised to DHS and 77 to MSP. The groups had similar patient demographics, pre-fracture status and in-hospital course. The quality of reduction was the same for each group, but the operative time was longer in the MSP group (61.6 vs. 50.1min, P=0.01). The rate of re-operation was low (3/86 in DHS and 2/77 in MSP) with no statistically significant difference. The functional outcomes were the same for both groups, with functional recovery scores at 6 months of 51.0% in the DHS arm and 49.7% in the MSP arm. CONCLUSIONS: The two techniques produced similar results for the clinically important outcomes of the need for further surgery and functional status of the patients at 6 months' follow-up.

A randomized prospective study on the treatment of intra-articular distal radius fractures: open reduction and internal fixation with dorsal plating versus mini open reduction, percutaneous fixation, and external fixation.

PURPOSE: To compare 2 methods of surgical treatment for displaced intra-articular fractures of the distal radius: open reduction and internal fixation with dorsal plating (Pi Plate; Synthes, Paoli, PA) versus mini open reduction with percutaneous K-wire and external fixation. METHODS: Patients with AO type C intra-articular distal radius fractures were randomized into 2 groups: open reduction and internal fixation and dorsal plating or external fixation and K-wires and mini-open reduction. Patients over the age of 70 years with any associated soft-tissue or skeletal injury to the same limb and pre-existing wrist arthrosis or disability were excluded from the study. Objective, subjective, and radiographic outcomes were assessed at 2 weeks, 4 to 6 weeks, 10 to 12 weeks, 6 months, and 1- and 2-year intervals. The minimum follow-up period was 6 months; the average follow-up period was 18 months. The principal outcome analyzed was the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcomes included grip strength, range of motion, surgical procedure time, complications, and radiographic parameters. The groups were equal with respect to age, gender, fracture subtype, and number of workers' compensation cases. RESULTS: No significant difference was found in the Disabilities of the Arm, Shoulder, and Hand scores, our primary outcome. The dorsal plate group, however, showed a higher complication rate when compared with the external fixator group. The plate group had significantly longer tourniquet times when compared with the external fixator group. The plate group also had higher levels of pain at 1 year when compared with the external fixator group; however, this equalized after hardware removal. The external fixator group showed an average grip strength of 97% compared with the normal side and 86% in the dorsal plate group. CONCLUSIONS: At midterm analysis the dorsal plate group showed a significantly higher complication rate compared with the external fixator group; therefore enrollment in the study was terminated. The dorsal plate group also showed statistically significant higher levels of pain, weaker grip strength, and longer surgical and tourniquet times. Based on these results we cannot recommend the use of dorsal plates in treating complex intra-articular fractures of the distal radius.

The use of a blade plate and autogenous cancellous bone graft in the treatment of ununited fractures of the proximal humerus.

Stable internal fixation is essential to obtain healing of an ununited fracture of the proximal humerus. Standard plate and screw fixation may be inadequate to secure a small, osteopenic proximal fragment. We used blade plates and autogenous cancellous bone graft to repair ununited fractures of the proximal humerus in 25 patients (19 women and 6 men) with a mean age of 61 years. Healing was documented in 23 of 25 patients (92%). Objective and subjective instruments documented substantial functional improvement in patients with healed fractures. The results were classified as good or excellent in 20 of 25 patients, and few complications were encountered. Blade plate fixation facilitates successful treatment of ununited fractures of the proximal humerus.

The role of psychological functioning in morbid obesity and its treatment with gastroplasty.

BACKGROUND: The authors evaluated the psychological characteristics of the morbidly obese. The condition-specific and quality-of-life characteristics of a large sample of vertical banded gastroplasty (VBG) patients were evaluated. The role that these psychological characteristics play in moderating the success of gastroplasty surgery, as well as the impact of surgery on quality of life, was examined. METHODS: This is a cross-sectional evaluative study of a clinical samples, with longitudinal follow-up and with non-surgical comparison groups. 89 morbidly obese individuals were assessed before VBG (but after having been accepted for surgery) and again 1.27 years after surgery. This group represents 98% of the patients who received VBG (i.e., a 2% dropout rate). We used established psychological measures (quality of life, adjustment to obesity, functional impairment, and eating attitudes), including a scale developed by our group specifically for morbid obesity, to identify distinct psychological profiles of the morbidly obese before surgery. RESULTS: The three profile groups differed significantly in psychological characteristics, ranging from high functioning (little emotional distress, functional impairment or dysfunctional eating) to poor functioning (high emotional distress, functional impairment and dysfunctional eating). The subgroups did not differ on pre-surgical weight, and did not differ from morbidly obese groups not seeking surgery. For the surgery group, regardless of pre-surgery psychological profile, VBG produced significant weight loss, maintained at 1 year after surgery. As well, surgery resulted in significant improvements in quality of life and psychological adjustment, especially in the profile group initially presenting with psychological disturbance. CONCLUSION: There was no evidence to suggest that those with pre-surgical psychological difficulties did more poorly with VBG. These data call into question screening out individuals with psychological problems from gastroplasty surgery. Furthermore, psychological difficulties, if they exist, appear more related to the nature of morbid obesity than to the character of the individual. Psychological difficulties pre-surgery were normalized following surgery.

The Obesity Adjustment Survey: development of a scale to assess psychological adjustment to morbid obesity.

OBJECTIVE: To develop a reliable and valid measure of distress, related to extreme obesity. DESIGN: Items related to distress over obesity were selected from the literature, clinical experience and from input provided by a gastroplasty patient support group. The items were assessed in a longitudinal study, with the body mass index (BMI) and psychological assessment occurring 2-6 months prior to, and 12 months following, gastroplasty surgery. SUBJECTS: 81 females and eight males (mean age 35.9 y) who had been accepted for gastroplasty surgery. All but two of the patients had BMIs > 40 (Mean = 48.11, s.d. = 6.84). MEASUREMENTS: BMIs were calculated using weight and height. Psychological characteristics were assessed using the Mental Health Inventory (MHI), the Sickness Impact Profile (SIP), and the Eating Inventory (EI). Demographic information was collected with a questionnaire. RESULTS: Attempts to factor analyse the 95 item questionnaire were unsuccessful. Alternatively, a shorter, 20 item questionnaire was developed. The questionnaire shows good test-retest reliability (r = 0.867), good internal consistency (coefficient alpha = 0.719), good face and construct validity, and is sensitive to pre-post surgical change. CONCLUSIONS: The Obesity Adjustment Survey (OAS) may be useful as a brief measure of distress in obese individuals. This measure can be used to index the psychological impact of gastroplasty surgery on psychological functioning, and can be used in future research as a disease-specific measure to predict success of surgery.

The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients.

Twenty-two elderly patients (average age, seventy-two years) who had an atrophic, unstable, ununited fracture of the humeral diaphysis were managed with plate-and-screw fixation and application of an autogenous bone graft from the iliac crest. Fifteen of the patients had had at least one previous operation in an attempt to obtain union of the fracture. One patient had an active infection and two had a quiescent infection, all with Staphylococcus epidermidis. The average duration of nonunion before the patients were first seen by us was two years and four months (range, five months to sixteen years). Fifteen of the nonunions were synovial. In each patient, at least one modification of the standard technique of plate-and-screw fixation was needed as a result of osteopenia. In order to enhance fixation, the standard protocol incorporated the use of a long plate (with an average of eleven holes and an average length that was 76 percent of that of the bone), a plate with a blade (used in thirteen patients), and replacement of loose, 4.5-millimeter cortical-bone screws with 6.5-millimeter cancellous-bone screws (twelve patients). Spiked nuts (Schuhli nut; Synthes, Paoli, Pennsylvania) that lock the screws to the plate, creating a solid point of fixation analogous to a blade, were incorporated into the protocol when they became available (used in six patients). In five limbs, the nonunion was associated with an osseous defect that could not be addressed by shortening of the bone alone. Three of these limbs were stabilized with a bridge plate that had been contoured to stand away from the bone at the site of nonunion (so-called wave-plate osteosynthesis), and the remaining two limbs were stabilized with a combination of intramedullary and extramedullary plates. In one of these two limbs, the extramedullary plate was contoured (that is, a wave plate). The fracture united in twenty (91 percent) of the patients. There was no progressive loosening or breakage of a fixation device, even in two patients who had radiographs that were suggestive of an incomplete union. Five of the patients were followed for a limited duration (average, one year and six months) as a result of death or illness. They had two excellent results, two good results, and one poor result according to a modification of the rating system of Constant and Murley. The remaining seventeen patients, including the two who had a persistent nonunion, were followed for an average of three years and one month (range, two years to five years and ten months). They had significant improvements in all of the functional scores at the most recent follow-up evaluation: the average score according to the modified system of Constant and Murley increased from 9 to 72 points (p < 0.001), the average score according to the Enforced Social Dependency Scale decreased from 39 to 9 points (p < 0.001), and the average score based on the Disabilities of the Arm, Shoulder, and Hand Questionnaire decreased from 77 to 24 points (p < 0.001). According to the scores based on the Disabilities of the Arm, Shoulder, and Hand Questionnaire, nine of the seventeen patients who had been followed for more than two years had an excellent result, four had a good result, two had a fair result, and the two who had a persistent nonunion had a poor result. Complications included postoperative delirium, a stitch abscess, transient radial nerve palsy, a fracture distal to the plate, and the need for a blood transfusion, in one patient each. Two patients had a fibrous union. There were no major medical complications. An unstable, united fracture of the humeral diaphysis can be extremely disabling and may threaten the ability of an elderly patient to function independently. Operative treatment can be very successful when the techniques of plate-and-screw fixation are modified to address osteopenia and relative or absolute loss of bone. Healing of the fracture substantially improves function and the degree of independence

Skin necrosis: an unusual complication of hyperphosphatemia during total parenteral nutrition therapy.

BACKGROUND: Hyperphosphatemia complicated by calcification of subcutaneous arteries and skin infarcts are very rarely reported in the absence of chronic renal failure (CRF). We describe identical lesions in an obese woman with sepsis. Hyperphosphatemia resulted from an unintended excess of phosphate in her total parenteral nutrition (TPN) formulations. She did not have CRF or hyperparathyroidism. METHODS: The patient's records during 37 weeks of hospitalization 12 years ago and, subsequently, her outpatient records were reviewed. RESULTS: During a 7-week period, the total elemental phosphorus infused daily, as divalent phosphate, ranged from 1.8 to 4.2 g, median 3.1, over triple the normal daily requirement. This excess was unintended. This occurred before the current practice of pharmacist-monitoring of TPN formulations, and possibly resulted from misinterpretation of a revised formulation sheet, newly introduced to the nursing units at the start of that period. Serum phosphorus increased to 3.02 mmol/L (normal 0.76 to 1.46 mmol/L). She developed calcification of subcutaneous arteries, which was complicated by widespread infarcts of the anatomically related skin and subcutis, apparently the result of hypoperfusion of these vessels during an episode of septic shock. The infarcts were heralded by unusual, blotchy skin discolorations. CONCLUSIONS: This report, illustrating a startling cutaneous complication associated with apparent misinterpretation of TPN formulations, demonstrates a pathogenetic relationship between hyperphosphatemia, calcification of subcutaneous arteries, and necrosis of the skin and subcutis in the absence of CRF and hyperparathyroidism and introduces a new differential diagnosis for unusual skin lesions appearing during TPN therapy.

TGF-beta 1 forms functionally normal bone in a segmental sheep tibial diaphyseal defect.

OBJECTIVE: Transforming growth factor-beta 1 (TGF-beta 1) is a polyfunctional regulatory cytokine that has been shown to have roles in extracellular matrix interactions, soft tissue healing, and osteogenesis. This study was undertaken to determine the efficacy of TGF-beta 1 in the formation of functionally normal bone in tibial-diaphyseal defects. METHOD: Seven hundred fifty micrograms of recombinant human TGF-beta 1 was added to a guanidine-extracted demineralised bone matrix (Gu-DBM) carrier and the implants were used to fill a 2.5 cm tibial diaphyseal defect in skeletally mature female sheep. The defects were allowed to heal over a 12-week period. After sacrifice, they were analyzed using four-point bending mechanical testing. RESULTS: Implants with TGF-beta 1 showed complete bony bridging of the defect and stress-strain curves similar to the normal contralateral limb, while implants with the carrier alone failed to bridge the gap. CONCLUSIONS: These results demonstrate the ability of TGF-beta 1 to induce new bone which has structural and functional characteristics similar to normal bone.

Body position, age and mass effect of adiposity on adipose tissue red cell flux in morbid obesity.

OBJECTIVE: To measure red cell flux of adipose tissue in morbidly obese patients' pannus in the upright and supine position to determine factors which would render the lower pannus susceptible to ischemic necrosis. DESIGN: A cohort study of morbidly obese subjects without ischemic necrosis. SETTING: University teaching hospital. PATIENTS: Twenty-three consecutive morbidly obese patients referred for gastroplasty. MEASUREMENTS: Red cell flux, measured as RMS voltage by a laser Doppler velocimeter. An optical fiber with a tip diameter of 250 mu was inserted into the upper and lower pannus and output recorded in the upright and supine positions. Other variables recorded were age, BMI, blood pressure and serum lipids. RESULTS: Adipose tissue red cell flux demonstrates considerable spatial and temporal heterogeneity from subject to subject and in various locations in the pannus. No differences in red cell flux were detected in response to change in position. However, regression analysis demonstrated that the gradient between the upper and lower abdomen in the supine position was increasingly positive with age and in the upright position it was increasingly positive with increasing weight or BMI. CONCLUSIONS: These data suggest that red cell flux is heterogeneously distributed in the abdominal pannus and is not greatly influenced by body position. However, with increasing age and adiposity there is a gradient for decreased red cell flux to the lower portion of the pannus. This may be a factor in rendering this part of the pannus prone to ischemic fat necrosis.

Structural changes in the subcutaneous compartment in morbid obesity.

Most of the excess fat that accumulates in the morbidly obese is accommodated in the subcutaneous compartment (SCC), specifically in the adipose tissue lobules of the panniculus adiposus which enlarge and expand the SCC. However, the fibroelastic septa that are attached to the skin on one side of the SCC and to the deep fascia on the other invest each lobule and thereby offer resistance to the enlarging lobules. We report observations made during pathologic examinations of the abdominal wall SCC that were surgically excised by abdominal dermo-panniculectomy from 48 morbidly obese subjects after gastroplasty and weight loss. Lobules were large but varied notably upwards in size and, to some extent, shape. Simultaneously upon incision of the SCC, the lobules bulged above and the septa retracted below the same cut surfaces. Light microscopy revealed disruptions of septal elastic fibers, calcification of septa and septal arteries and necrosis of adipocytes, all sparsely distributed. Certain questions and facts emerge from these observations. Are the variations in lobule sizes normal, or do they reflect uneven fat deposition or mobilization during weight gain or loss respectively? Is there any correlation between lobule and adipocyte sizes? The tightly coupled phenomena of lobule-bulging and septal-retraction indicate that the lobules and septa are subjected to compressional and tensile stresses respectively in the intact, non-incised SCC. The histologic changes might be consequences of these stresses. Studies of the variations in body fat distribution and in adipocyte size have contributed to an understanding of obesity pathogenesis. The relevance of the present findings is unknown at this time, but these appear to have potential implications for studies of the morphogenesis of obesity. Confirmation of these findings, particularly the lobule variations, is required so that these can be compared with those in never-obese subjects and in morbidly obese subjects without prior weight loss.

Hepatic artery pseudoaneurysms in acute pancreatitis.

The authors present a case of multiple intrahepatic pseudoaneurysms complicating acute gallstone pancreatitis, and they review the relevant literature. The complementary roles of ultrasonography, computed tomography and arteriography are illustrated. Although necrotizing vasculitis with resultant aneurysmal changes in peripancreatic vessels is a recognized complication of chronic pancreatitis, similar pseudoaneurysms have rarely been described in association with acute pancreatitis.

Peutz-Jeghers syndrome. Association of duodenal and bilateral breast cancers in the same patient.

A female patient with Peutz-Jeghers syndrome successively developed bilateral breast carcinoma and malignant transformation of a duodenal hamartomatous polyp, from which she died.

Segmental colonic transit time.

Mean segmental transit time of radiopaque markers through the right colon, left colon and rectosigmoid areas of adults and children has been calculated form their distribution on consecutive plain films of the abdomen. Overall mean transit does not differ significantly in the large bowel between adults and children. However, there are regional differences within the colon in relation to age. Mean transit time in the right colon is 13.8 hours in adults and 7.7 in children (p less than 0.01). Corresponding values in the left colon are 14.1 and 8.7 hours (p less than 0.02) and, in the rectum, 11 and 12.4 hours (p = NS). The percentage of the mean total large bowel transit time spent in the right colon, left colon and rectosigmoid area are respectively for adults and children 33 +/- 4 and 28 +/- 3 per cent (p = NS); 39 +/- 4 and 32 +/- 4 per cent (p = NS); and 28 +/- 4 and 41 +/- 4 per cent (p less than 0.05), indicating a relative stagnation in the rectosigmoid area of children. These physiologic differences may have implications in diseased states.

Small erythematous mucosal plaques: an endoscopic sign of Crohn's disease.

A non-ulcerated granulomatous lesion of the large bowel mucosa has been found in 11 patients, nine of whom already had or eventually developed classical features of Crohn's disease. These lesions, which are multiple, consist of small well-circumscribed raised erythematous plaques surrounded by normal mucosa. At biopsy there is focal haemorrhage of the lamina propria, rupture of the crypts, release of mucus, and frank granulomatous reaction with giant cell formation. The lesion may be reversible or be followed by the classical mucosal ulcerations. They may occur in the presence or the absence of classical lesions of Crohn's disease elsewhere in the gastrointestinal tract. As this non-ulcerated lesion may occur in isolation, it may provide the initial clue to the diagnosis of Crohn's disease.