Humeral fractures in the elderly: treatment with a reamed intramedullary locking nail.

In the elderly person, comorbidities combined with lower functional demands tend to indicate non-operative treatment; however, fast functional recovery is mandatory to prevent loss of independency and social ability. This retrospective follow-up study included 40 people with a mean age of 75 (range 60-87) years. They had all received treatment with a reamed intramedullary nail for humeral fracture; 21 were operated after a mean of 6 (range 0-16) days, and 19 after a mean of 28 (range 9-63) days after a primary decision for non-operative treatment. In all, 5 cases (12.5%) were lost to follow-up. The primary healing rate was 94% (33/35) after a mean of 17 (range 6-61) weeks; 14% (5/35) needed re-operation, in 2 cases because of healing problems. Functional results could be assessed in 18 cases: the median Neer score was 90 (range 45-97) points and the median Morrey score 98 (range 74-100) points. The relative functional scores were 94 (range 89-101) and 100 (range 97-100) points, respectively. All functional scores were independent of introduction site and time to treatment. On the basis of these results we conclude that treatment of humeral fractures in the elderly with an intramedullary nail leads to good healing and functional results, and an acceptable re-operation rate.

Failure of reamed nailing in humeral non-union: an analysis of 26 patients.

The use of an intramedullary nail in the treatment of humeral non-unions remains controversial. This study evaluated the treatment of humeral delayed and non-unions with reamed nailing and compression. In a retrospective analysis of prospectively gathered data from 26 cases all treated with the Telescopic Locking Nail (TLN), the healing rate after the first intervention for non-union was 58%. After one or more re-interventions combined with an external cancellous bone graft at some time during follow-up, 90% of the 21 patients with complete follow-up eventually healed after a mean of 22 months. A total of 49 procedures with a mean of 1.9 per patient were needed. After a mean follow-up of 65 (range 24-88) months, we conducted a study to assess the functional results in the shoulder and elbow. Twelve patients were suitable for inclusion. We used the Neer and Morrey score for shoulder and elbow function, respectively. For the Neer score the median was 91 points and for the Morrey score 94 points. The outcome suggests that simple reamed nailing of humeral non-union is insufficient. Reamed interlocked nailing is feasible, provided that the primary intervention for non-union is combined with an external cancellous bone graft.

The long gamma nail in the treatment of 329 subtrochanteric fractures with major extension into the femoral shaft.

OBJECTIVE: To study the outcome of treating extensive proximal femoral fractures with the long Gamma nail. DESIGN: Retrospective study, with a minimum follow-up of a year. SETTING: 24 hospitals throughout The Netherlands. SUBJECTS: 329 patients with primary proximal femoral fractures. MAIN OUTCOME MEASURES: Functional results and complications. RESULTS: 19 patients died in hospital and 6 were lost to follow-up. Of the remaining 304 who were fully documented, 241 (80%) became fully mobile, 59 (19%) moderately mobile, and 4 remained bedridden. 264 patients had no pain, 38 had moderate pain and used oral painkillers, and 2 had severe pain that was difficult to treat. Major technical complications occurred in 17 patients: alignment and locking gave rise to most problems, 4 patients developed deep infections, and 7 patients needed additional measures before the fracture was solid. CONCLUSIONS: The long Gamma nail in the treatment of extensive proximal femoral fractures gave good functional results with acceptable rates of complications and union problems.

Treatment of impending and actual pathological femoral fractures with the long Gamma nail in The Netherlands.

OBJECTIVE: To compare the results of stabilising impending and actual pathological femoral fractures using the long Gamma nail with the published results of other methods. DESIGN: Retrospective study. SETTING: 20 hospitals throughout The Netherlands. PATIENTS: 101 patients with metastases in 110 femurs, which were stabilised with a long Gamma nail. MAIN OUTCOME MEASURES: Functional results and complications. RESULTS: Minimum follow-up was 1.5 years or until death, Mean survival was 12 months (range 0-82). 14 patients died in hospital; 5 had technical complications and fat embolism was suspected in 3 patients. 92% of the patients became mobile and pain was absent or acceptable in 93%. CONCLUSION: The use of the long Gamma nail produces better functional results, fewer technical complications, and an incidence of general complications no different from those reported for other methods.

Treatment of fractures of femur and tibia with the telescopic locking nail: design of a new implant and the first clinical results.

BACKGROUND: This study was carried out to evaluate the first clinical experiences with the telescopic locking nail (TLN). The TLN is a newly developed universal locking nail system for both femur and tibia that permits cyclic dynamic loading at the fracture site while weightbearing. The nail can also be used for static interlocking or for compression of the fracture elements. The nail is strong enough to permit immediate weightbearing, and the diameter of 9 mm allows unreamed introduction in many cases. MATERIALS: Seventy-one consecutive patients were treated with the TLN, 24 patients with femoral and 47 patients with tibial fracture or nonunion. RESULTS: Functional outcome, complication rate, and union rate were comparable to other interlocking nail systems. CONCLUSION: Its distinctive biomechanical properties and its universal application in both femur and tibia make the TLN a sophisticated, yet in practice simple, new asset in the practice of intramedullary nailing.

One-stage lengthening and derotational osteotomy of the femur stabilised with a gamma nail.

OBJECTIVES: To study the results of a one-stage lengthening and derotational osteotomy stabilised with a Gamma nail. DESIGN: Retrospective study. SETTING: 2 hospitals, The Netherlands. PATIENTS: 5 patients after failed osteosynthesis of femoral fractures. INTERVENTIONS: Mean lengthening of 3 cm and derotation of 30 degrees. MAIN OUTCOME MEASURES: Complications and functional results, after a mean follow-up of 43 months (range 30-57). RESULTS: Two patients required dynamisation and a cancellous bone graft to achieve union, which resulted in 1 and 1.5 cm loss of length. One patient had a temporary peroneal neurapraxy. No infections were observed. CONCLUSIONS: Our method is not an ultimate solution, but is suitable for one-stage lengthening and derotation osteotomies.

Presenting treatment protocols with Web technology.

This paper describes a Web-based version of a protocol information system (ProtoVIEW) with which a wide range of diagnostic or therapeutic protocols can be retrieved and viewed. The Web-based version contains all functionalities of the non web-based version plus several new functionalities. The web version contains an X-ray viewer and a great deal of interactivity such as validation of electronic patient data forms. The most important additional function is the context sensitive protocol support which may lead to improved protocol adherence. Finally, the web-based version can be accessed from any working place since patient data and protocols are stored centrally.

Functional and radiological outcome after intra-articular tibial plateau fractures.

A follow-up study was performed to assess the functional and radiological outcome after operative treatment of tibial plateau fractures. Of 62 patients operated upon from 1985 to 1993, 46 patients were traced and re-examined. Follow-up averaged 60 months. Three functional scores were applied: the HSS knee score, the Lysholm score and the Tegner score. Radiographs obtained at follow-up were rated for deformity and signs of arthrosis, using a score described by Reswick and Niwayama. Patients reported most functional complaints during the first 3 years and after 6 years. Patients seen between 3 and 6 years after injury showed better functional scores. Arthritic changes were seen from 5 years after the fracture. Patients over 60 years of age seemed to suffer less functional loss than younger patients, indicating that operative treatment should not be withheld on grounds of age alone.

Evaluating performance of the Revised Trauma score as a triage instrument in the prehospital setting.

In this study, we have evaluated the performance of the Revised Trauma Score (RTS) as a triage instrument in the prehospital setting in The Netherlands. To this end we analysed prehospital and clinical data on 398 injured patients in an urban-rural area in the east of the Netherlands. Our study included injured patients aged over 15 who were alive at the time the ambulance arrived. We found a comparatively low prevalence of major injuries in the prehospital setting, which varied with the definition used (for patients with an HTI-ISS > or = 18, it was 5.8 per cent, for HTI-ISS > or = 20 it was 3.7 per cent; for a modified HTI-ISS criterion it was 5.3 per cent and 2.7 per cent needed major emergency therapy). Estimates of sensitivity were also rather low and varied with the definition used (38 per cent for HTI-ISS > or = 18; 56 per cent for HTI-ISS > or = 20, 45 per cent for the modified HTI-ISS criterion and 76 per cent for major emergency treatment). The specificity and the predictive value of a lowered RTS, however, were 94 per cent and 26 per cent respectively for all definitions used. The conclusion of this study is that the performance of the RTS in this study population is poorer than expected from earlier studies. The low prevalence of major injuries in the prehospital setting in The Netherlands and the distribution of case severity may possibly explain these results.

First experience and complications with the long Gamma nail.

Treatment of proximal femoral fractures is difficult. A retrospective analysis of 92 patients treated with a custom-made extended gamma nail with a mean follow up of 4 months is presented. The early results of this new method are promising. The indications for the use of the long gamma nail were intertrochanteric fractures with extension to the subtrochanteric region, imminent and pathologic fractures of the intertrochanteric and subtrochanteric region, mostly in elderly patients, proximal femoral fractures, and combination injuries in multiple trauma patients and delayed unions. In 67 cases the patients were primarily treated with a long Gamma nail. In 25 cases the nail was used after the failure of initial treatment. Complications occurred in 32 patients; however, 88 patients were able to walk at the end of the study. The advantage of this new method is that with a closed surgical technique full weight bearing directly after the operation is achieved. The long Gamma nail provides a procedure by which most complex fractures in the proximal femur can be managed.

[The dynamic hip screw in medial fractures of the femoral neck: results in 51 patients]. / De dynamische heupschroef bij mediale fracturen van het collum femoris: resultaten bij 51 patiënten.

Femoral neck fractures are common in the elderly, especially in female patients. Pseudarthrosis and femoral head necrosis were complications with a high incidence in earlier days, when the femoral neck fracture was treated by obsolete osteosynthesis techniques. Replacement of the femoral head by an endoprosthesis was introduced in the seventies because of these complications. This hemiarthroplasty also causes many postoperative complications. With the development of the dynamic hip screw for trochanteric and subtrochanteric fractures a new technique for stabilising femoral neck fractures has been introduced. In a retrospective study (average follow-up: 3.4 years; 3 months-6 years; median: 3.6 years) of 51 patients with a femoral neck fracture who were treated with a DHS the short- and long-term postoperative complications (femoral head necrosis and pseudarthrosis) were determined. The most frequent short-term complications were bleeding (10 patients), the need for blood transfusion (10), decubitus (6), wound infection (5), urinary tract infection (5). Femoral head necrosis was seen in two patients more than 30 days after the operation. Pseudarthrosis was not observed. Because of the low complication rate, we can conclude that DHS osteosynthesis, on a correct indication, can be used as first choice in femoral neck fractures.

[Reconstruction of the tibial plateau fracture with arthroscopic monitoring without arthrotomy]. / Reconstructie van de tibiaplateaufractuur onder artroscopische controle zonder artrotomie.

In the period from October 1986 to November 1988 in the Medisch Spectrum Twente of Enschede, 25 patients were treated for a tibial plateau fracture by means of arthroscopic surgery. The mean hospital stay was 18 days. Active movement of the leg was prescribed from the fifth day. The results were very good in 23 and poor in 2 patients. Complications such as wound infections and skin necrosis were not seen. Additional meniscal lesions could be diagnosed and treated better using this surgical technique. In addition, the limited incisions and consequently the avoidance of extensive arthrotomy allowed faster rehabilitation and a higher probability of healing the chondral tissue.

[Functional treatment of Colles fractures and the relation of anatomic recovery and function]. / Functionele behandeling van Colles-fracturen en het verband tussen anatomisch herstel en functie.

Functional treatment of Colles fractures is a recently developed approach to fracture injury. It aims to bring about faster recovery and a better functional end result by permitting early motion and function by means of a functional brace. Early motion and function, however, might jeopardize the anatomical result. Whether an inferior anatomical result jeopardizes the functional end result is not clear, as the relationship between anatomy and function has not been established. In a prospective clinical study it was concluded that in displaced Colles fractures functional treatment with a below-the-elbow functional brace offers little advantage over conventional plaster of Paris immobilisation. Minimally displaced Colles fractures (volar angle greater than or equal to 0 degrees) should be treated with a bandage after one week of plaster immobilisation. The relationship between the anatomical and functional end result is weak and probably depends on initial displacement and complications. To improve the functional result after a Colles fracture, prevention and better treatment of complications seem to be more important than improvement of the method of fracture treatment of the anatomical end result.

Transposition of the semitendinosus tendon for early repair of medial and anteromedial laxity of the knee.

In 15 patients with acute medial (N = 8) or anteromedial (N = 7) laxity of the knee, reconstruction of the torn ligaments was combined with the use of the semitendinosus tendon as a dynamic extra-articular stabilizer. The postoperative regimen consisted of early mobilization in a mobile cast with full weight bearing. An evaluation 1 to 3 years after surgery revealed good results in 14 cases, and one fair result as graded using the Marshall score (mean score 45.3, SD 2.9). Isokinetic measurements of knee flexion and extension showed no loss of strength. Equally good results have been reported in conservatively treated isolated MCL lesions. In case of a combination of a MCL lesion and an ACL lesion the results reported are usually worse. This treatment regimen seems to be a good concept in acute anteromedial laxity of the knee and cannot be considered anything but an alternative in isolated MCL lesions.

Early functional treatment of supination-eversion stage-II ankle fractures: preliminary results.

The preliminary results of early functional treatment of 30 patients with a grade-II supination-eversion fracture of the ankle according to Lauge-Hansen are discussed. The treatment of all patients consisted of splint immobilization for one week, followed by the application of a functional brace (Push Brace Medium) and immediate full weight bearing and functional training. All fractures healed without complications. Ankle function, radiographic findings and anamnestic complaints were monitored. The loss of ankle function diminished to 3.2 degrees +/- 4.9 degrees plantar flexion and to 1.7 degrees +/- 5.3 degrees dorsal flexion after one year follow up, none of the patients had significant complaints of pain or swelling. Radiography showed consolidation with callus formation in all cases. The grade-II supination-eversion fracture is a stable fracture which allows early functional treatment with the support of a Push Brace Medium. This results in an inexpensive, simple and comfortable therapy. A prospective randomized clinical trial is necessary to show the advantages of functional treatment over cast immobilization. Long-term follow-up will have to ascertain the theoretic risk of posttraumatic osteo-arthritis.

Dome fracture of the talus.

Three cases of transchondral fracture of the dome of the talus are reported. Two were treated surgically, one conservatively. A review of the literature is presented and the relative values of surgical intervention and conservative therapy are discussed.

Clinical diagnosis, arthrography, stress examination and surgical findings after inversion trauma of the ankle.

In a series of 921 patients with acute inversion trauma of the ankle joint, the diagnostic features of lateral ligamentous ruptures were evaluated. Patients with proven lateral ligamentous rupture (150 patients in this series) were submitted to a prospective trial to compare three methods of treatment. In the 50 patients operated upon, the results of clinical diagnosis, stress radiography, and ankle arthrography were compared with surgical findings. Clinical diagnosis proved to be of very little value. The positive signs of ankle arthrography showed a reliability of 96% in predicting ligamentous rupture. Inversion stress radiography under full anesthesia showed a reliability of 92%, but the same investigation under local anesthesia, however, was only 68%.