A prospective study on socioeconomic aspects of fracture of the proximal femur.

A prospective survey of hip fracture incidence and outcome was conducted to evaluate their socioeconomic impact. Over the course of 1 year, 404 hip fractures were recorded in 339 women and 65 men following minor or moderate trauma. The subjects' ages were 82.8 +/- 10.0 years (mean +/- SD): 84.1 +/- 9.2 in female and 76.4 +/- 13.7 in male subjects. The overall annual incidence was 104.4/100,000; the incidence in women was 167.1 versus 35.3 in men, with a crude female-to-male ratio of 4.7. However, when adjusted for age, this ratio was 2.7. When adjusted to the 1985 U.S.A. population, the incidence rates were 68.6 overall, 108.8 female, and 26.3 male, and were, respectively, 119.1, 188.8, and 46.1 when adjusted to the 1992 Swiss population. As compared with 105 age-matched non-hip-fracture fallers studied in the same emergency ward, fracture subjects lived more often in nursing homes and took cardiovascular drugs (p < 0.001). The mean length of stay in the orthopedic ward was 16.3 +/- 12.0 days (median 14; range 2-193 days), for a total of 6566 bed-days representing 19.8% of available bed-days. The mean length of stay in rehabilitation hospitals was 63.6 +/- 52.6 days (median 50; range 2-349 days), for a total of 17,099 bed-days, representing 5.2% of available bed-days. For patients who where independent before fracture, the greater length of stay was associated with advanced age and consumption of cardiovascular drugs. The total cost of hospital stay amounted to approximately $44,000 per patient. Mortality was 3.2% in the orthopedic ward and 10.8% in rehabilitation hospitals, for an overall in-hospital mortality rate of 10.4%. Overall, the 1-year mortality was 23.8% (21.5% for women and 35.4% for men), and it was significantly higher than in the general population (p < 0.001). Prognostic factors for mortality were age, sex, consumption of cardiovascular drugs, and previous living circumstances. One year after fracture, 62.6% of the fracture patients had returned to their previous living circumstances, but 17.9% needed a more care-intensive environment. The likelihood of returning to autonomous living circumstances 1 year after fracture was higher in younger subjects, in females, in those living with a partner, and in those in overall better health before the fracture. This prospective survey highlights the high socioeconomic impact and burden of osteoporotic fractures of the proximal femur.

Novel animal model for studying the molecular mechanisms of bacterial adhesion to bone-implanted metallic devices: role of fibronectin in Staphylococcus aureus adhesion.

Infection around metallic implants is a rare but severe complication of orthopaedic surgery. A novel animal model mimicking conditions of internal fixation devices was developed to evaluate the role of host proteins adsorbed on metallic devices in promoting adhesion and colonization of the material surfaces by Staphylococcus aureus. Small plates made of pure titanium were either fixed (three screws per plate) onto the iliac bones of guinea pigs or implanted into their subcutaneous space as controls. Five to 6 weeks after surgery, the plates and screws were removed from the previously killed animals, carefully rinsed in buffer, and tested in an in vitro assay of S. aureus adhesion to metallic surfaces. To evaluate the role of fibronectin in staphylococcal adhesion to explanted plates and screws, a mutant of S. aureus that is specifically defictive in fibronectin adhesion due to decreased expression of the fibronectin adhesin was compared with its isogenic parental strain. A significant reduction in adhesion of the fibronectin adhesin-defective mutant compared with the parental strain occurred on both the subcutaneously implanted and bone-implanted metallic plates. The results of this specific biological assay suggest that fibronectin is present on bone-implanted metallic devices and promotes attachment of S. aureus to their surfaces. This novel experimental model should help, to characterize several parameters of bacterial adhesion to metallic orthopaedic devices and to develop novel anti-adhesive strategies for preventing such infections.

[Progressive fragmentation of a bipartite patella: apropos of a case]. / Fragmentation progressive d'une patella bipartita. A propos d'un cas.

PURPOSE OF THE STUDY: Progressive dissolution of the supero-lateral fragment of a bipartite patella is reported. MATERIAL AND METHODS: The patient, a 44 year old professor of gymnastics, was examined for long standing anterior knee pain. For many years, his daily activities included forceful knee flexion exercises. Serial radiographs, between 1986 and 1990, revealed a progressive fragmentation of the accessory ossification center and accompanying calcific deposits in the lateral patellar retinaculum. RESULTS: Surgical excision of the calcific mass and accessory ossification center relieved the painful symptomatology completely, allowing the patient full normal function at one year's follow-up. DISCUSSION: The pathological findings were compatible with a dystrophic calcinosis associated with detritic synovitis. A pathogenic mechanism is hypothesized for this unusual and progressive course of a common condition: Repetitive trauma, in this case forceful knee flexion exercises, shear microscopic bony fragments of the poorly vascularized accessory ossification center. These microscopic fragments act as deposits of an apatite crystal which go on to induce the secondary soft tissue calcifications seen in our patient.

Effects of calcium supplements on femoral bone mineral density and vertebral fracture rate in vitamin-D-replete elderly patients.

The efficacy of calcium (Ca) in reducing bone loss is debated. In a randomized placebo-controlled double-masked study, we investigated the effects of oral Ca supplements on femoral shaft (FS), femoral neck (FN) and lumbar spine (LS) bone mineral density (BMD), and on the incidence of vertebral fracture in vitamin-D-replete elderly. Ninety-three healthy subjects (72.1 +/- 0.6 years) were randomly allocated to three groups receiving 800 mg/day Ca in two different forms or a placebo for 18 months. Sixty-three patients (78.4 +/- 1.0 years) with a recent hip fracture were allocated to two groups receiving the two forms of Ca without placebo. FS BMD changes in Ca-supplemented non-fractured women were significantly different from those in the placebo group (+0.6 +/- 0.5% v -1.2 +/- 0.7%, p < 0.05). There was no difference in effect between the two forms of Ca. The changes of +0.7 +/- 0.8% v -1.7 +/- 1.6% in FN BMD of Ca-supplemented women and the placebo group did not reach statistical significance. In fractured patients, FS, FN and LS BMD changes were -1.3 +/- 0.8, +0.3 +/- 1.6 and +3.1 +/- 1.2% (p < 0.05 for the last). The rate of new vertebral fractures was 74.3 and 106.2 fractures per 1000 patient-years in Ca-supplemented non-fractured subjects and in the placebo group, respectively, and 144.0 in Ca-supplemented fractured patients. Thus, oral Ca supplements prevented a femoral BMD decrease and lowered vertebral fracture rate in the elderly.

Role of fibronectin in staphylococcal adhesion to metallic surfaces used as models of orthopaedic devices.

Staphylococcal infection of various prosthetic and internal fixation devices is a major complication associated with orthopaedic surgery. This study investigated the role of the host protein fibronectin in promoting adhesion of Staphylococcus aureus and Staphylococcus epidermidis to metallic surfaces representing materials used for orthopaedic devices. Pure human fibronectin was adsorbed in vitro onto coverslips (0.8 x 0.8 cm) of stainless steel, pure titanium, or titanium-aluminum-niobium alloy. In vitro bacterial adhesion was promoted more strongly by the metallic surfaces coated with fibronectin than by albumin-coated controls for two strains of S. aureus and one strain of S. epidermidis. Furthermore, with the fibronectin-coated coverslips, bacterial adhesion to titanium alloy was significantly greater than adhesion to stainless steel. Adhesion of the three staphylococcal strains was promoted more strongly by coverslips explanted from the subcutaneous space of guinea pigs and tested under similar conditions than by albumin-coated controls. Incubation of either in vitro fibronectin-coated or explanted metallic coverslips with anti-fibronectin antibodies produced a significant decrease in staphylococcal adhesion. These results suggest that the presence of fibronectin on the surface of implanted metallic devices is an important determinant of colonization of orthopaedic biomaterials by staphylococci.

Fat embolism syndrome.

Twenty cases of clinically patent fat embolism syndrome (FES) were observed at the authors' institution between 1964 and 1989. There were 4 deaths (20%). The injury severity score (ISS) was computed for each patient upon admission and ranged from 9 to 50 (median, 17). The ISS was significantly higher in the 4 deceased patients (P = .014). The incidence of FES amounted to 0.26% of all patients hospitalized with at-risk fractures (femoral and tibial shaft fractures and pelvic fractures). The findings of the 25-year study indicate the following: (1) clinically patent postfracture FES is rare; (2) FES is significantly more frequent in patients with several at-risk fractures than in those with one at-risk fracture (P < .0003); and (3) prognosis appears to be more directly related to ISS than to FES itself.

Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur.

Malnutrition has been often suggested as contributing to both the high incidence of hip fracture in elderly people and its complications. In a recent prospective controlled randomized study, the clinical outcome of elderly patients with osteoporotic fracture of the proximal femur (hip fracture) improved by giving a simple oral dietary supplement. This study, however, did not prove that protein was responsible for the clinical improvement since the supplement also contained vitamins and minerals. We addressed this question by comparing the clinical outcome and bone mineral density (BMD) changes in elderly patients with hip fracture, receiving two different dietary supplements with different protein contents. Sixty-two patients (mean age 82) admitted into the orthopedic ward for fracture of the proximal femur were randomized into two groups. One group (n = 33) received 250 ml/day of an oral nutritional supplement containing protein (20.4 g), mineral salts (Ca: 0.525 g) and vitamins A = 750 IU; D3 = 25 IU) for a mean of 38 days. A control group (n = 29) received the same supplement dose, but with no protein, for the same period of time. The clinical course was significantly better in the group receiving protein, with 79% having a favorable course as compared to 36% (p less than 0.02) in the control group during the stay in the recovery hospital. The rate of complications and deaths was also significantly lower in the protein-supplemented vs the control group (52 vs 80%, p less than 0.05) 7 months after hip fracture. The median hospital stay was significantly lower in the protein-supplemented group (69 vs 102 days, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiology of fractures of the proximal femur in Geneva: incidence, clinical and social aspects.

Fracture of the proximal femur (hip fracture) as a consequence of osteoporosis is an important public health problem. Its incidence, which rises with age, varies according to geographical location and race. There is no information concerning hip fracture in Switzerland, which is a Western country with a particularly aged population. During 1987, 361 patients with hip fracture were recorded in the University of Geneva Hospital, which is the main referral center for a population of about 376,000 inhabitants. This represented 94% of all hip fractures occurring in the region. A moderate trauma was reported in 329 cases (91.1%). The overall annual incidence was 96.1 per 100,000 population (146.9 for women and 39.8 for men). When only hip fractures following moderate trauma were considered, the incidence was 87.6 per 100,000 population (138.8 for women and 30.8 for men). Rare under the age of 65, hip fracture incidence increased exponentially in older subjects. The mean age of patients with hip fracture was 82.0 years in women and 75.7 years in men. The ratio of cervical to trochanteric fracture was 1.03 and 1.12 in women and men, respectively. The mean length of stay in the orthopaedic ward was 30.5 days, and the total costs amounted to 8.8 million Swiss francs for hip fracture associated with moderate trauma. Forty-seven percent of subjects were transferred to another hospital for recovery or rehabilitation. During the stay in the orthopaedic ward, the mortality rate was 8.2%. These results emphasize the high incidence and cost of hip fractures in a region of Switzerland where the population is particularly old.(ABSTRACT TRUNCATED AT 250 WORDS)

Preferential low bone mineral density of the femoral neck in patients with a recent fracture of the proximal femur.

Bone mass is an important determinant of resistance to fractures. Whether bone mineral density (BMD) in subjects with a fracture of the proximal femur (hip fracture) is different from that of age-matched controls is still debated. We measured BMD of the femoral neck (FN) on the opposite side to the fracture, as well as femoral shaft (FS) and lumbar spine (LS) BMD by dual-photon absorptiometry in 68 patients (57 women and 11 men, mean age 78.8 +/- 1.0) 12.4 +/- 0.8 days after hip fracture following a moderate trauma. These values were compared with BMD of 93 non-fractured elderly control subjects (82 women and 11 men), measured during the same period. As compared with the controls, FN BMD was significantly lower in fractured women (0.592 +/- 0.013 v. 0.728 +/- 0.014 g/cm2, P less than 0.001) and in fractured men (0.697 +/- 0.029 v. 0.840 +/- 0.052, P less than 0.05). Expressed as standard deviations above or below the mean BMD of age and sex-matched normal subjects (Z-score), the difference in FN BMD between fractured women and controls was highly significant (-0.6 +/- 0.1 v. +0.1 +/- 0.1, P less than 0.001). As compared with mean BMD of young normal subjects, BMD was decreased by 36.9 +/- 1.4 and 22.4 +/- 1.5% (P less than 0.001) in fractured and control women, respectively. There was no significant difference between FN BMD of 33 women with cervical and 24 with trochanteric hip fractures (0.603 +/- 0.017 v. 0.577 +/- 0.020). FN BMD was lower than 0.705 g/cm2 in 90% of fractured women.(ABSTRACT TRUNCATED AT 250 WORDS)

Dietary supplementation in elderly patients with fractured neck of the femur.

59 elderly patients (mean age 82) with femoral neck fractures were randomised into two groups. 27 patients received daily an oral nutrition supplement (250 ml, 20 g protein, 254 kcal) for a mean of 32 days; 32 patients acted as controls. On admission most patients had nutritional deficiencies. Despite being offered adequate quantities, nutritional requirements were not met during the hospital stay. Clinical outcome was significantly better in the supplemented group (56% favourable course vs 13% in controls) during the stay in the convalescent hospital. The rates of complications and deaths were also significantly lower in supplemented patients (44% vs 87%). 6 months after the fracture the rates of complications and mortality were significantly lower in supplemented patients (40% vs 74%). The median duration of hospital stay was significantly shorter in the supplemented group (24 vs 40 days). Thus the clinical outcome of elderly patients with femoral neck fracture can be improved by once daily dietary oral supplementation.

[A combination of dihydroergotamine and acetylsalicylic acid--prevention of postoperative thromboembolic complications. Clinical study in orthopedics]. / Association de dihydroergotamine et d'acide acétylsalicylique--prophylaxie des complications thromboemboliques postopératoires. Etude clinique en orthopédie.

202 patients undergoing surgery involving the lower limbs were given antithrombotic treatment for at least 21 days, or until they had regained full mobility. Following subcutaneous prophylaxis with a combination of heparin and dihydroergotamine, two oral regimens were compared in a controlled and randomized prospective study. The first treatment consisted of a combination of acetylsalicylic acid (ASA) and dihydroergotamine (DHE), and the second of acenocoumarol. The radiofibrinogen uptake test was carried out in high-risk patients (i.e. those undergoing hip surgery) to detect deep-vein thrombosis. No statistically significant difference was found between the two groups. However, the ASA/DHE combination enjoyed better patient acceptance and was much easier to use.

Delayed internal fixation of femoral shaft fractures--is there an advantage? A review of 320 fractures.

We have reviewed 402 traumatic fractures of the femoral shaft, 320 of which had been treated by operation and had a long follow-up. Of these, 228 closed fractures and 37 open fractures had been stabilised by plating. There was no significant difference in healing between those stabilised early and those having delayed internal fixation. Re-fracture after removal of the implant occurred more often after early operation. All 55 fractures treated by intramedullary nailing healed and there were no re-fractures after nail removal. We found no correlation between delay before operation and the incidence of postoperative infection.

[Postoperative infection of fractures of the femoral diaphysis treated by osteosynthesis. Long-term outcome]. / L'infection post-opératoire des fractures de la diaphyse fémorale traitées par ostéosynthèse. Evolution à long terme.

The authors have operated on 284 simple fractures, complicated by 12 post-operative infections (4.2 per cent) and 43 compound fractures, complicated by four infections (9.3 per cent). All the fractures were treated by plating. Thirteen of the infected cases have received long-term follow-up - ten after simple fractures and three after compound fractures. Nine out of the ten cases following simple fractures have healed, eight retaining the plate until consolidation and two being considered as infected non-unions. One of these two healed secondarily after fresh fixation and the other is still draining after a second operation, but has united. Two out of the four cases following compound fractures have already healed. The two others were considered as infected non-union and healed after fresh fixation. It is concluded that infection after fracture of the femoral shaft is a serious complication, but healing can be obtained in almost all cases. No amputation was needed.

[Aseptic necrosis of the femoral head in young adults]. / Nécrose aseptique de la tête fémorale chez le jeune adulte.

Aseptic necrosis of the femoral head is a well-defined entity. The underlying diseases originate from very different types of pathological conditions. Alcoholism, cortisone therapy, gout or hyperuricemia, sickle cell anaemia and others all lead, through various pathways, to the impairment of the medullary blood flow. In many instances, a compartment syndrome can be demonstrated in the femoral head. Death of the osteocytes follows bone marrow necrosis. Revascularisation originates in the periphery of the necrotic segment. Vascular buds and fibroblasts invade the medullary space. New bone is laid over the necrotic trabeculae. Mechanical failure results from changes in the bony framework at three different levels. The subchondral boneplate may be weakened by the process of revascularisation, the necrotic trabeculae may fail because of diminished stiffness and strength, and overloading has been demonstrated at the junction between dead and living bone. Elevation of the intramedullary pressure is the first objective sign of impending or established bone necrosis. Scintigraphy with Technetium 99 m - Sulphur colloid can now show the early stages of marrow necrosis. Roentgenographic changes only appear in a later phase of the disease. Aseptic necrosis must be considered as involving both hips, unless proven otherwise. Attention given to the "silent hip" may allow salvage and prevent the occurrence of osteo-arthritic changes leaving merely unilateral disease. As long as the geometrical shape of the femoral head is maintained operation may well prove useful. The aim at this stage is to prevent collapse. It is impossible to know in the early stages whether mechanical failure will occur, but there is general agreement that the femoral head will eventually undergo deformation. A spherical epiphysis is therefore considered a success. All the conservative methods aim to decompress the medullary cavity. Core biopsy, curettage, bone grafting and intertrochanteric osteotomy all have their advocates. After fracture of the subchondral bone plate has occurred, there is evidence that grafts are unable to restore the strength of the necrotic area. Intertrochanteric osteotomy brings under the main load-bearing zone a vital part of the femoral head. Varus osteotomy can be successful if necrosis has spared sufficient of the lateral portion of the head. Rotation osteotomies, as proposed by Sugioka, are more radical and difficult operations. The published results are promising. Revascularisation of the weight-bearing area by pedicle grafts has been attempted, alone or in addition to osteotomy.(ABSTRACT TRUNCATED AT 400 WORDS)

The value of computerized tomography in fractures of the pelvic ring.

Thirty four fractures of the pelvic ring were examined by computerized tomography and the findings compared with those obtained with conventional radiography. CT scanning enabled precise delineation of the fracture sites in the posterior ring. A new classification is proposed which defines five patterns of fracture of the posterior ring. Computerized tomography is a valuable aid in planning operation in these injuries.

Humeral retrotorsion and glenohumeral relationship in the normal shoulder and in recurrent anterior dislocation (scapulometry).

The authors' roentgenographic technique provides precise assessment of the glenohumeral relationship on the basis of two-plane examination. A group of 50 normal male subjects serve as the basis for determining normal values for the following angles or lines: projected and corrected cephalodiaphyseal angle, projected and corrected humeral retrotorsion, glenoid inclination, angle of attack, glenoid retroversion, dimension of glenoid, width of humeral head, and contact index. Two groups of patients suffering from recurrent anterior dislocation (RAD) are compared with the normal group. The shoulders with RAD do not differ significantly from the normal ones. Humeral retrotorsion, in particular, is identical. Significant differences are found between affected and unaffected sides in unilateral RAD. The diameter of the glenoid and the contact index are smaller on the dislocated side. Because the projected values seldom differ by more than 10 degrees from the calculated values, if the authors' roentgenographic technique is used, the figures can generally be accepted without correction.