Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience

The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes. In total, 101 patients (53 female, 48 male) with a mean age of 50.9 years (19 to 76) with minimally displaced GT fractures were recruited to a prospective observational cohort study. During the first year after injury, patients underwent experiential assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score and assessment of associated injuries using MRI performed within two weeks of injury. The primary outcome was the one-year DASH score. Multivariate analysis was used to assess the effect of patient demographic factors, complications, and associated injuries, on outcome. The mean DASH score improved from 42.3 (SD 9.6) at six weeks post-injury, to 19.5 (SD 14.3) at one-year follow-up (p < 0.001), but outcomes were mixed, with 30 patients having a DASH score > 30 at one year. MRI revealed a range of associated injuries, with a full-thickness rotator cuff tear present in 19 patients (19%). Overall, 11 patients (11%) developed complications requiring further operative intervention; 20 patients (21%) developed post-traumatic secondary shoulder stiffness. Multivariate analysis revealed a high-energy mechanism (p = 0.009), tobacco consumption (p = 0.033), use of mobility aids (p = 0.047), a full-thickness rotator cuff tear (p = 0.002), and the development of post-traumatic secondary shoulder stiffness (p = 0.035) were independent predictors of poorer outcome. The results of nonoperative management of minimally displaced GT fractures are heterogeneous. While many patients have satisfactory early outcomes, a substantial subgroup fare much worse. There is a high prevalence of rotator cuff injuries and post-traumatic shoulder stiffness, and their presence is associated with poorer patient experience. Furthermore, patients who have a high-energy injury, smoke, or use walking aids, have worse outcomes.

Factors affecting a patient's experience following the open Latarjet procedure to treat recurrent anterior shoulder instability

The open Latarjet procedure is a widely used treatment for recurrent anterior instability of the shoulder. Although satisfactory outcomes are reported, factors which influence a patient's experience are poorly quantified. The aim of this study was to evaluate the effect of a range of demographic factors and measures of the severity of instability on patient-reported outcome measures in patients who underwent an open Latarjet procedure at a minimum follow-up of two years. A total of 350 patients with anterior instability of the shoulder who underwent an open Latarjet procedure between 2005 and 2018 were reviewed prospectively, with the collection of demographic and psychosocial data, preoperative CT, and complications during follow-up of two years. The primary outcome measure was the Western Ontario Shoulder Instability Index (WOSI), assessed preoperatively, at two years postoperatively, and at mid-term follow-up at a mean of 50.6 months (SD 24.8) postoperatively. The secondary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. The influence of the demographic details of the patients, measurements of the severity of instability, and the complications of surgery were assessed in a multivariate analysis. The mean age of the patients was 25.5 years (22 to 32) and 27 (7.7%) were female. The median time to surgery after injury was 19 months (interquartile range (IQR) 13 to 39). Seven patients developed clinically significant complications requiring further intervention within two years of surgery. The median percentage WOSI deficiency was 8.0% (IQR 4 to 20) and median QuickDASH was 3.0 (IQR 0 to 9) at mid-term assessment. A minority of patients reported a poorer experience, and 22 (6.3%) had a > 50% deficiency in WOSI score. Multivariate analysis revealed that consumption of ≥ 20 units of alcohol/week, a pre-existing affective disorder or epilepsy, medicolegal litigation, increasing time to surgery, and residing in a more socioeconomically deprived area were independently predictive of a poorer WOSI score. Although most patients treated by an open Latarjet procedure have excellent outcomes at mid-term follow-up, a minority have poorer outcomes, which are mainly predictable from pre-existing demographic factors, rather than measures of the severity of instability.

Achieving spatially precise diagnosis and therapy in the mammalian gut using synthetic microbial gene circuits

The mammalian gut and its microbiome form a temporally dynamic and spatially heterogeneous environment. The inaccessibility of the gut and the spatially restricted nature of many gut diseases translate into difficulties in diagnosis and therapy for which novel tools are needed. Engineered bacterial whole-cell biosensors and therapeutics have shown early promise at addressing these challenges. Natural and engineered sensing systems can be repurposed in synthetic genetic circuits to detect spatially specific biomarkers during health and disease. Heat, light, and magnetic signals can also activate gene circuit function with externally directed spatial precision. The resulting engineered bacteria can report on conditions in situ within the complex gut environment or produce biotherapeutics that specifically target host or microbiome activity. Here, we review the current approaches to engineering spatial precision for in vivo bacterial diagnostics and therapeutics using synthetic circuits, and the challenges and opportunities this technology presents.

Bioengineering bacterial encapsulin nanocompartments as targeted drug delivery system

The development of Drug Delivery Systems (DDS) has led to increasingly efficient therapies for the treatment and detection of various diseases. DDS use a range of nanoscale delivery platforms produced from polymeric of inorganic materials, such as micelles, and metal and polymeric nanoparticles, but their variant chemical composition make alterations to their size, shape, or structures inherently complex. Genetically encoded protein nanocages are highly promising DDS candidates because of their modular composition, ease of recombinant production in a range of hosts, control over assembly and loading of cargo molecules and biodegradability. One example of naturally occurring nanocompartments are encapsulins, recently discovered bacterial organelles that have been shown to be reprogrammable as nanobioreactors and vaccine candidates. Here we report the design and application of a targeted DDS platform based on the Thermotoga maritima encapsulin reprogrammed to display an antibody mimic protein called Designed Ankyrin repeat protein (DARPin) on the outer surface and to encapsulate a cytotoxic payload. The DARPin9.29 chosen in this study specifically binds to human epidermal growth factor receptor 2 (HER2) on breast cancer cells, as demonstrated in an in vitro cell culture model. The encapsulin-based DDS is assembled in one step in vivo by co-expressing the encapsulin-DARPin9.29 fusion protein with an engineered flavin-binding protein mini-singlet oxygen generator (MiniSOG), from a single plasmid in Escherichia coli. Purified encapsulin-DARPin_miniSOG nanocompartments bind specifically to HER2 positive breast cancer cells and trigger apoptosis, indicating that the system is functional and specific. The DDS is modular and has the potential to form the basis of a multi-receptor targeted system by utilising the DARPin screening libraries, allowing use of new DARPins of known specificities, and through the proven flexibility of the encapsulin cargo loading mechanism, allowing selection of cargo proteins of choice.

The accuracy of computed tomography for clavicle non-union evaluation

BACKGROUND

The primary aim of this study is to determine the accuracy of CT scanning when evaluating non-union of the clavicle.

METHODS

A retrospective review was performed of all CT scans undertaken for suspected nonunion of midshaft clavicle fractures over a 10-year period. The influence of scan timing, callus and patient characteristics was evaluated.

RESULTS

One hundred eighty-four CT scans were analysed. No patient was incorrectly diagnosed with union (n = 85). Ninety-nine scans were reported as non-union with inadequate bridging callus, 19 of which were united at operation or on repeat CT imaging and represented delayed unions. Atrophic callus was found in 57 patients and all of which had a confirmed non-union (positive predictive value 100%). A hypertrophic callus was found in 42 patients, all of the delayed unions were found in this group (positive predictive value for non-union 55%, p < 0.001). CT compared to radiographs showed greater inter-observer agreement for union (weighted kappa 0.75 vs. 0.50 respectively). Overall, CT is 100% sensitive and 81.7% specific for non-union diagnosis.

DISCUSSION

CT has excellent accuracy to determine clavicle union but approximately one in five suspected non-unions went onto unite. Hypertrophic callus finding resulted in a delayed union in approximately half of the cases in our study.

FlopR: An Open Source Software Package for Calibration and Normalization of Plate Reader and Flow Cytometry Data

The measurement of gene expression using fluorescence markers has been a cornerstone of synthetic biology for the past two decades. However, the use of arbitrary units has limited the usefulness of these data for many quantitative purposes. Calibration of fluorescence measurements from flow cytometry and plate reader spectrophotometry has been implemented previously, but the tools are disjointed. Here we pull together, and in some cases improve, extant methods into a single software tool, written as a package in the R statistical framework. The workflow is validated using Escherichia coli engineered to express green fluorescent protein (GFP) from a set of commonly used constitutive promoters. We then demonstrate the package's power by identifying the time evolution of distinct subpopulations of bacteria from bulk plate reader data, a task previously reliant on laborious flow cytometry or colony counting experiments. Along with standardized parts and experimental methods, the development and dissemination of usable tools for quantitative measurement and data analysis will benefit the synthetic biology community by improving interoperability.

Routine fixation of displaced midshaft clavicle fractures is not cost-effective: a cost analysis from a randomized controlled trial

AIMS

The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures.

PATIENTS AND METHODS

A cost analysis was conducted within a randomized controlled trial comparing conservative management (n = 92) versus early plate fixation (n = 86) of displaced midshaft clavicular fractures. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). The Six-Dimension Short-Form Health Survey (SF-6D) score was used as the preference-based health index to calculate the cost per QALY at 12 months after the injury.

RESULTS

The mean 12-month SF-6D was 0.9522 (95% confidence interval (CI) 0.9355 to 0.9689) following conservative management and 0.9607 (95% CI 0.9447 to 0.9767) following fixation, giving an advantage for fixation of 0.0085, which was not statistically significant (p = 0.46). The mean cost per patient was £1322.69 for conservative management and £5405.32 for early fixation. This gave an ICER of £480 309.41 per QALY. For a threshold of £20 000 per QALY, the benefit of fixation would need to be present for 24 years to be cost-effective compared with conservative treatment. Linear regression analysis identified nonunion as the only factor to adversely influence the SF-6D at 12 months (p < 0.001).

CONCLUSION

Routine plate fixation of displaced midshaft clavicular fractures is not cost-effective. Nonunion following conservative management has an increased morbidity with comparable expense to early fixation. This may suggest that a targeted approach of fixation in patients who are at higher risk of nonunion would be more cost-effective than the routine fixation of all displaced fractures. Cite this article: Bone Joint J 2019;101-B:995-1001.

The Influence of Shortening on Clinical Outcome in Healed Displaced Midshaft Clavicular Fractures After Nonoperative Treatment

BACKGROUND

We aimed to evaluate the effect of clavicular shortening, measured with 3-dimensional computed tomography (3DCT), on functional outcomes and satisfaction in patients with healed displaced midshaft clavicular fractures up to 1 year following injury.

METHODS

The data used in this study were collected as part of a multicenter, prospective randomized controlled trial of open reduction and plate fixation compared with nonoperative treatment for acute, displaced midshaft clavicular factures. Patients who were randomized to nonoperative treatment and had healed by 1 year were included in the present study. Clavicular shortening relative to the uninjured, contralateral clavicle was measured on 3DCT. Outcome analysis was conducted at 6 weeks, 3 months, 6 months, and 1 year following injury and included the Disabilities of the Arm, Shoulder and Hand (DASH), Constant, and Short Form-12 (SF-12) scores and patient satisfaction.

RESULTS

In the original trial, 105 patients were randomized to nonoperative treatment. Thirteen patients were lost to follow-up, leaving 92 patients, and an additional 16 (17%) developed nonunion and were excluded from the present study. Of the remaining 76 patients, 48 who had a 3DCT scan that included the whole length of both clavicles were included in the present study. The shortening of the injured clavicles, relative to the contralateral side, was a mean (and standard deviation) of 11.3 ± 7.6 mm, with a mean proportional shortening of 8%. Proportional shortening did not significantly correlate with the DASH (p ≥ 0.42), Constant (p ≥ 0.32), or SF-12 (p ≥ 0.08) scores at any point during follow-up. There was no significant difference in the mean DASH or Constant scores at any follow-up time point when the cutoff for shortening was defined as 1 cm (p ≥ 0.11) or as 2 cm (p ≥ 0.35). There was no significant difference in clavicular shortening between satisfied and unsatisfied patients (p ≥ 0.49).

CONCLUSIONS

The present study demonstrated no association between shortening and functional outcome or satisfaction in patients with healed displaced midshaft clavicular fractures up to 1 year following injury.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Smoking status and the Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle

AIMS

This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery.

METHODS

We performed a retrospective study of 88 patients aged between 16 and 60 years that were managed non-operatively.

RESULTS

The rate of symptomatic nonunion requiring surgery was 14% (n = 13). Smoking (odds ratio (OR) 40.76, 95% confidence intervals (CI) 1.38 to 120.30) and the six week Disabilities of the Arm Shoulder and Hand (DASH) score (OR 1.11, 95% CI 1.01 to 1.22, for each point increase) were independent predictors of nonunion. A six week DASH score of 35 or more was identified as a threshold value to predict nonunion using receiver operating characteristic curve analysis. Smoking and the threshold value in the DASH and were additive risk factors for nonunion, when neither were present the risk of nonunion was 2%, if one or the other were present the nonunion rate was between 17% to 20%, and if both were present the rate increased to 44%.

DISCUSSION

Patients with either of these risk factors, which include approximately half of all patients sustaining displaced midshaft fractures of the clavicle, are at an increased risk of developing a symptomatic non-union.

TAKE HOME MESSAGE

Smoking and failure of functional return at six weeks are significant predictors of nonunion of the midshaft of the clavicle. Such patients warrant further investigation as to whether they would benefit from early surgical fixation in order to avoid the morbidity of a nonunion.

Role of MCP-1 on inflammatory processes and metabolic dysfunction following high-fat feedings in the FVB/N strain

Background

MCP-1 is known to be an important chemokine for macrophage recruitment. Thus, targeting MCP-1 may prevent the perturbations associated with macrophage-induced inflammation in adipose tissue. However, inconsistencies in the available animal literature have questioned the role of this chemokine in this process. The purpose of this study was to examine the role of MCP-1 on obesity-related pathologies.

Methods

Wild-type (WT) and MCP-1 deficient mice on an FVB/N background were assigned to either low-fat-diet (LFD) or high-fat-diet (HFD) treatment for a period of 16 weeks. Body weight and body composition were measured weekly and monthly, respectively. Fasting blood glucose and insulin, and glucose tolerance were measured at 16 weeks. Macrophages, T cell markers, inflammatory mediators, and markers of fibrosis were examined in the adipose tissue at sacrifice.

Results

As expected, HFD increased adiposity (body weight, fat mass, fat percent, and adipocyte size), metabolic dysfunction (impaired glucose metabolism and insulin resistance) macrophage number (CD11b⁺F480⁺ cells, and gene expression of EMR1 and CD11c), T cell markers (gene expression of CD4 and CD8), inflammatory mediators (pNFκB and pJNK, and mRNA expression of MCP-1, CCL5, CXCL14, TNF-α, and IL-6), and fibrosis (expression of IL-10, IL-13, TGF-β, and MMP2) (P<0.05). However, contrary to our hypothesis, MCP-1 deficiency exacerbated many of these responses resulting in a further increase in adiposity (body weight, fat mass, fat percent and adipocyte size), metabolic dysregulation, macrophage markers (EMR1), inflammatory cell infiltration, and fibrosis (formation of type I and III collagens, mRNA expression of IL-10 and MMP2) (P<0.05).

Conclusions

These data suggest that MCP-1 may be a necessary component of the inflammatory response required for adipose tissue protection, remodeling, and healthy expansion in the FVB/N strain in response to HFD feedings.

Oral precursor lesions and malignant transformation--who, where, what, and when?

Oral potentially malignant disorders (PMD) are recognisable mucosal conditions that have an unpredictable risk of transformation to squamous cell carcinoma (SCC), a lethal and deforming disease of rising incidence. Contemporary management is based on clinical recognition of suspicious lesions and incisional biopsy to enable histopathological assessment and grading of dysplasia, together with excision of high-risk lesions and long-term surveillance. However, it is impossible to predict clinical outcome or risk of malignant transformation. Our aim was to evaluate the relevance of previously identified oral precursor lesions for the development of SCC and staging of disease. We therefore retrospectively reviewed 1248 cases of SCC diagnosed in oral and maxillofacial surgery units at Newcastle upon Tyne and Sunderland hospitals between 1996 and 2009. Of them, 58 identifiable precursor lesions became malignant but only 25 had been dysplastic on initial biopsy; 19 of 33 non-dysplastic lesions exhibited lichenoid inflammation only. SCC arose most often on the ventrolateral tongue and floor of the mouth, with a mean transformation time of 29.2 months. Transformation time was significantly shorter in men (p=0.018) and those over 70 years of age (p=0.010). Patients who consumed more than 21 units of alcohol/week and those who had had interventional laser surgery to treat precursor lesions, had higher-staged tumours (p=0.048). Although retrospective, this study shows that the results of incisional biopsy and grading of dysplasia have limited use as predictive tools, and supports the view that cancer may arise in the absence of recognisable epithelial dysplasia. Our findings confirm the importance of clinical vigilance and active surveillance in the management of all patients with clinically suspicious oral lesions, irrespective of the histological findings.

Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial

BACKGROUND

There is a growing trend to treat displaced midshaft clavicular fractures with primary open reduction and plate fixation; whether such treatment results in improved patient outcomes is debatable. The aim of this multicenter, single-blinded, randomized controlled trial was to compare union rates, functional outcomes, and economic costs for displaced midshaft clavicular fractures that were treated with either primary open reduction and plate fixation or nonoperative treatment.

METHODS

In a prospective, multicenter, stratified, randomized controlled trial, 200 patients between sixteen and sixty years of age who had an acute displaced midshaft clavicular fracture were randomized to receive either primary open reduction and plate fixation or nonoperative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores. Union was evaluated with use of three-dimensional computed tomography. Complications were recorded, and an economic evaluation was performed.

RESULTS

The rate of nonunion was significantly reduced after open reduction and plate fixation (one nonunion) as compared with nonoperative treatment (sixteen nonunions) (relative risk = 0.07; p = 0.007). Group allocation to nonoperative treatment was independently predictive of the development of nonunion (p = 0.0001). Overall, DASH and Constant scores were significantly better after open reduction and plate fixation than after nonoperative treatment at the time of the one-year follow-up (DASH score, 3.4 versus 6.1 [p = 0.04]; Constant score, 92.0 versus 87.8 [p = 0.01]). However, when patients with nonunion were excluded from analysis, there were no significant differences in the Constant scores or DASH scores at any time point. Patients were less dissatisfied with symptoms of shoulder droop, local bump at the fracture site, and shoulder asymmetry in the open reduction and plate fixation group (p < 0.0001). The cost of treatment was significantly greater after open reduction and plate fixation (p < 0.0001).

CONCLUSIONS

Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes. However, the improved outcomes appear to result from the prevention of nonunion by open reduction and plate fixation. Open reduction and plate fixation is more expensive and is associated with implant-related complications that are not seen in association with nonoperative treatment. The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures.

Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures of the clavicle

BACKGROUND

Identification of patients at higher risk of nonunion after diaphyseal clavicular fractures is desirable to improve patient counseling and enable targeted surgical treatment.

METHODS

Seventy-nine percent (941 of 1196) of diaphyseal clavicular fractures were followed to union or nonunion. Demographic, injury, and radiographic characteristics associated with nonunion were determined with use of bivariate and multivariate statistical analyses.

RESULTS

In patients who were eighteen years of age or older, 125 (13.3%) of the fractures had clinical and radiographic evidence of nonunion. Factors significantly associated with nonunion on bivariate analysis were sex, smoking status, overall fracture displacement, overlap, translation, and comminution. The factors that maintained significance on multivariate analysis were smoking (odds ratio, 3.76), comminution (odds ratio, 1.75), and fracture displacement (odds ratio, 1.17). If all displaced midshaft fractures were managed operatively, 7.5 procedures would need to be undertaken to prevent a single nonunion. If only fractures with a predicted probability of ≥40% were managed operatively, the number of patients managed operatively to prevent a single nonunion would fall to 1.7.

CONCLUSIONS

Thirteen percent of displaced diaphyseal fractures in patients who were at least eighteen years of age did not heal. Smoking was the strongest risk factor, and smoking cessation should be an integral part of treatment. The probability of nonunion in a particular individual can be estimated with use of a statistical model based on known risk factors. This information can be useful when counseling the patient even though nonunion remains difficult to predict accurately in that individual. The number who would need to be treated to prevent a single nonunion can be reduced by identifying those at higher risk.

Instability of the shoulder following seizures

Dislocation of the shoulder may occur during seizures in epileptics and other patients who have convulsions. Following the initial injury, recurrent instability is common owing to a tendency to develop large bony abnormalities of the humeral head and glenoid and a susceptibility to further seizures. Assessment is difficult and diagnosis may be missed, resulting in chronic locked dislocations with protracted morbidity. Many patients have medical comorbidities, and successful treatment requires a multidisciplinary approach addressing the underlying seizure disorder in addition to the shoulder pathology. The use of bony augmentation procedures may have improved the outcomes after surgical intervention, but currently there is no evidence-based consensus to guide treatment. This review outlines the epidemiology and pathoanatomy of seizure-related instability, summarising the currently-favoured options for treatment, and their results.

Frozen shoulder

Frozen shoulder is commonly encountered in general orthopaedic practice. It may arise spontaneously without an obvious predisposing cause, or be associated with a variety of local or systemic disorders. Diagnosis is based upon the recognition of the characteristic features of the pain, and selective limitation of passive external rotation. The macroscopic and histological features of the capsular contracture are well-defined, but the underlying pathological processes remain poorly understood. It may cause protracted disability, and imposes a considerable burden on health service resources. Most patients are still managed by physiotherapy in primary care, and only the more refractory cases are referred for specialist intervention. Targeted therapy is not possible and treatment remains predominantly symptomatic. However, over the last ten years, more active interventions that may shorten the clinical course, such as capsular distension arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features of frozen shoulder. We also outline the current treatment options, review the published results and present our own treatment algorithm.

Injuries associated with traumatic anterior glenohumeral dislocations

BACKGROUND

A number of shoulder girdle injuries are associated with acute anterior glenohumeral dislocations. In the present study we evaluated the prevalence of neurological deficits, greater tuberosity fractures, and rotator cuff injuries in a population of unselected patients who presented with a traumatic anterior glenohumeral dislocation.

METHODS

A prospective trauma database was used to record the demographic details on 3633 consecutive patients (2250 male patients and 1383 female patients with a mean age of 47.6 years) who had sustained a traumatic anterior glenohumeral dislocation between 1995 and 2009. On the basis of these data, we assessed the prevalence of and risk factors for ultrasound-proven rotator cuff tears, tuberosity fractures, and neurological deficits occurring in association with the dislocation.

RESULTS

Of the 3633 patients who had a dislocation, 492 patients (13.5%) had a neurological deficit following reduction and 1215 patients (33.4%) had either a rotator cuff tear or a greater tuberosity fracture. A dislocation with a neurological deficit alone was found in 210 patients (5.8%), a dislocation with a rotator cuff tear or a greater tuberosity fracture was found in 933 patients (25.7%), and a combined injury pattern was found in 282 patients (7.8%). Female patients with an age of sixty years or older who were injured in low-energy falls were more likely to have a rotator cuff tear or a greater tuberosity fracture. The likelihood of a neurological deficit after an anterior glenohumeral dislocation was significantly increased for patients who had a rotator cuff tear or a greater tuberosity fracture (relative risk, 1.9 [95% confidence interval, 1.7 to 2.1]; p < 0.001).

CONCLUSIONS

The prevalence of rotator cuff tear, greater tuberosity fracture, or neurological deficit following primary anterior glenohumeral dislocation is greater than previously appreciated. These associated injuries may occur alone or in combined patterns. Dislocations associated with axillary nerve palsy have similar demographic features to isolated dislocations. Injuries associated with a rotator cuff tear, greater tuberosity fracture, or complex neurological deficit are more common in patients sixty years of age or older. Careful evaluation of rotator cuff function is required for any patient with a dislocation associated with a neurological deficit, and vice versa.

Proximal humeral fractures due to blunt trauma producing skin compromise

We identified 16 patients with a mean age of 56.5 years (31 to 86) from a large consecutive series of patients with proximal humeral fractures over a 15-year period, who had sustained a fracture with skin compromise after a blunt injury. The study group represented 0.2% of 7825 proximal humeral fractures treated during this period and all had a displaced Neer two-part fracture pattern. Two patterns of skin injury were identified: in ten patients there was skin penetration at the time of the original injury, and the other six patients initially had closed injuries. These six patients had fracture fragments penetrating the muscular envelope to lie subcutaneously producing either early skin tethering (two patients) or delayed skin penetration and sinus formation (four patients). The pattern of injury to the soft-tissue envelope and the fracture pattern were similar for all injuries. Treatment of these injuries was determined by the initial severity of the soft-tissue injury and the medical status of the patient. We currently favour open reduction and internal fixation of these fractures wherever possible, owing to the high rate of nonunion with non-operative management.

The extended deltoid-splitting approach to the proximal humerus: variations and extensions

Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures.

Proximal humeral fractures: current concepts in classification, treatment and outcomes

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery. This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

The treatment of open femoral fractures with bone loss

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing. The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy. Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.

Metastatic adenocarcinoma after intramedullary fixation of a tibial fracture: A report of two cases

We present two cases of metastatic lung cancer which occurred at the site of a previously united tibial fracture. Both patients were treated with a locked intramedullary nail. The patients presented with metastases at the site of their initial fracture approximately 16 and 13 months after injury respectively. We discuss this unusual presentation and review the relevant literature. We are unaware of any previous reports of a metastatic tumour occurring at the site of an orthopaedic implant used to stabilise a non-pathological fracture. These cases demonstrate the similar clinical presentation of infection and malignancy: a diagnosis which should always be considered in such patients.

Proximal humeral fractures with a severe varus deformity treated by fixation with a locking plate

We treated 47 patients with a mean age of 57 years (22 to 88) who had a proximal humeral fracture in which there was a severe varus deformity, using a standard operative protocol of anatomical reduction, fixation with a locking plate and supplementation by structural allografts in unstable fractures. The functional and radiological outcomes were reviewed. At two years after operation the median Constant score was 86 points and the median Disabilities of the Arm, Shoulder and Hand score 17 points. Seven of the patients underwent further surgery, two for failure of fixation, three for dysfunction of the rotator cuff, and two for shoulder stiffness. The two cases of failure of fixation were attributable to violation of the operative protocol. In the 46 patients who retained their humeral head, all the fractures healed within the first year, with no sign of collapse or narrowing of the joint space. Longer follow-up will be required to confirm whether these initially satisfactory results are maintained.

The epidemiology of calcaneal fractures

BACKGROUND

Calcaneal fractures are rare, but debilitating injuries, which occur frequently in younger individuals. The economic impact of the residual long-term disability that may occur after these injuries is therefore disproportionate to their incidence. The aim of this study was to review the epidemiology and injury patterns of this injury.

METHODS

Data was extracted from a computer database, which prospectively coded all orthopaedic trauma events in a single unit between January 1995 and June 2005. Over this period 697 patients sustaining 752 fractures (55 bilateral) were treated in our unit. The patient's demographic details were prospectively recorded, together with details of their injury and primary treatment. The radiographs of a subgroup of patients were retrospectively examined in detail.

RESULTS

The annual incidence of fracture was 11.5 per 100,000, and occurred 2.4 times more frequently in males than females. In males, the incidence was 16.5/100,000/year, with a peak incidence in the age range 20-29 (21.6/100,000/year). In females, the overall incidence was 6.26/100,000/year, with a more even spread throughout the age cohorts and showing a gradual increase in incidence towards the post-menopausal years. The majority of fractures were sustained in falls from a height (71.5%), and 64.3% of these were from 6 feet and above. Only 18.8% of fractures occurred in the workplace, and although manual workers made up the largest occupational group, significant numbers occurred in both unemployed and the retired. Most injuries occurred in isolation but the most commonly seen concomitant injuries were lower limb (13.2%) or spinal injuries (6.3%). Conventional radiography in a subgroup of the patients showed an average Böhler's angle of 16.5 degrees with no difference between the males and females. There was a strong association between the severity of the fracture, as assessed using the Sanders classification on computerised tomography, and the degree of depression of the Böhler's angle (p=0.002).

Upregulation of Eps8 in oral squamous cell carcinoma promotes cell migration and invasion through integrin-dependent Rac1 activation

Oral squamous cell carcinoma (OSCC) is a lethal disease and early death usually occurs as a result of local invasion and regional lymph node metastases. Current treatment regimens are, to a certain degree, inadequate, with a 5-year mortality rate of around 50% and novel therapeutic targets are urgently required. Using expression microarrays, we identified the eps8 gene as being overexpressed in OSCC cell lines relative to normal oral keratinocytes, and confirmed these findings using RT-PCR and western blotting. In human tissues, we found that Eps8 was upregulated in OSCC (32% of primary tumors) compared with normal oral mucosa, and that expression correlated significantly with lymph node metastasis (P=0.032), suggesting a disease-promoting effect. Using OSCC cell lines, we assessed the functional role of Eps8 in tumor cells. Although suppression of Eps8 produced no effect on cell proliferation, both cell spreading and migration were markedly inhibited. The latter cell functions may be modulated through the small GTP-ase, Rac1 and we used pull-down assays to investigate the role of Eps8 in Rac1 signaling. We found that alphavbeta6- and alpha5beta1-integrin-dependent activation of Rac1 was mediated through Eps8. Knockdown of either Eps8 or Rac1, inhibited integrin-dependent cell migration similarly and transient expression of constitutively active Rac1 restored migration of cells in which Eps8 expression had been suppressed. We also showed that knockdown of Eps8 inhibited tumor cell invasion in an organotypic model of OSCC. These data suggest that Eps8 and Rac1 are part of an integrated signaling pathway modulating integrin-dependent tumour cell motility and identify Eps8 as a possible therapeutic target.

Cognitive function and cerebral emboli after primary hip arthroplasty

Transcranial Doppler ultrasound has been used to detect cerebral emboli after hip arthroplasty. The cognitive effects of these embolic events are unclear. The aim of this study was to assess cognitive change after primary cemented hip arthroplasty using a range of neuropsychological tests and to measure intraoperative cerebral embolic load. Twenty primary cemented total hip arthroplasties underwent a series of cognitive tests before and at four days after surgery. A range of validated tests assessed: global cognitive function; verbal fluency and speed; immediate and delayed memory recall; attention and mental processing speeds. Intra-operative transcranial Doppler ultrasound monitoring of the middle cerebral artery for embolic signals was also performed. A one-sample Wilcoxon signed-rank test compared median cognitive results post-pre surgery and a Mann-Whitney U test established if there was a cognitive difference between those patients who had detectable cerebral emboli and those who did not. Scatter plot graphs were also used to establish any correlation between the embolic load and clinical cognitive dysfunction. A significant (p<0.01) difference was noted in specific tests assessing mental processing speed, visual searching and sustained and divided attention following surgery. Intra-operative cerebral embolic signals were detected in 11 out of 20 patients and the majority occurred with femoral component cementation and hip reduction. There was no difference in cognitive dysfunction between those patients who had detectable cerebral embolic signals and those who did not and there appeared to be no direct correlation between the size of the embolic load and the level of cognitive dysfunction.

Disorders of the sternoclavicular joint

The sternoclavicular joint is vulnerable to the same disease processes as other synovial joints, the most common of which are instability from injury, osteoarthritis, infection and rheumatoid disease. Patients may also present with other conditions, which are unique to the joint, or are manifestations of a systemic disease process. The surgeon should be aware of these possibilities when assessing a patient with a painful, swollen sternoclavicular joint.

Spontaneous compartment syndrome in association with simvastatin-induced myositis

Compartment syndrome as a result of simvastatin-induced myositis is extremely rare. This case discusses a patient with spontaneous onset compartment syndrome that necessitated four-compartment fasciotomy. A thorough investigation into its cause highlighted statin-induced myositis as the most likely aetiological agent. When investigating a patient with unexplained spontaneous compartment syndrome it is important to consider drug-induced myositis. This case reinforces the difficulty faced in diagnosing spontaneous compartment syndrome.

Fractures of the distal humeral articular surface

Fractures of the distal humeral articular surface which do not involve the medial and lateral columns are often more extensive than is apparent from plain radiographs. This retrospective study describes the epidemiology of this injury using modern classification systems and compares pre-operative radiography with operative findings. The study group included 79 patients with a mean age of 47 years (13 to 91). The annual incidence was 1.5 per 100,000 population, and was highest in women over the age of 60. The majority of the fractures (59; 75%) were sustained in falls from standing height. Young males tended to sustain more high-energy injuries with more complex fracture patterns. In 24% of cases (19) there was a concomitant radial head fracture. Classification from plain radiographs often underestimates the true extent of the injury and computed tomography may be of benefit in pre-operative planning, especially in those over 60 years of age.

Distal femoral fractures treated by hinged total knee replacement in elderly patients

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile.

Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low.

A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.

The early response to major trauma and intramedullary nailing

The stress response to trauma is the summation of the physiological response to the injury (the 'first hit') and by the response to any on-going physiological disturbance or subsequent trauma surgery (the 'second hit'). Our animal model was developed in order to allow the study of each of these components of the stress response to major trauma. High-energy, comminuted fracture of the long bones and severe soft-tissue injuries in this model resulted in a significant tropotropic (depressor) cardiovascular response, transcardiac embolism of medullary contents and activation of the coagulation system. Subsequent stabilisation of the fractures using intramedullary nails did not significantly exacerbate any of these responses.

An investigation into the practice of tongue piercing in the South West of England

OBJECTIVE

To investigate the prevalence and range of complications following tongue piercing.

METHODS

A survey of individuals with tongue piercings ('piercees') and tongue piercers was undertaken in the South West of England. One hundred and twenty-three piercees completed a self-administered questionnaire and 22 piercers took part in an interviewer-led questionnaire.

RESULTS

The mean age of an individual having a tongue piercing was 19 years old. Almost all the subjects reported problems following piercing; early problems were mainly due to tissue trauma, whereas later, ingestion of jewellery and tooth fracture were common events. A minority (7%) of piercees required the advice of a healthcare professional following tongue piercing. The majority of piercers reported adequate cross-infection measures and enquired about their clients' health prior to piercing. However, only one piercer was aware of the risk of bacterial endocarditis following tongue piercing. Most of the piercers reported that they would advise their clients to attend an Accident and Emergency department if a serious complication ensued.

CONCLUSION

Tongue piercing may be associated with significant short-term and long-term morbidity, including tooth damage. Although the majority of piercers interviewed reported adequate cross-infection controls, knowledge of the medical risks associated with tongue piercing varied widely.

Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury).

Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries.

A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated.

Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial

BACKGROUND

Elderly people who have a fracture are at high risk of another. Vitamin D and calcium supplements are often recommended for fracture prevention. We aimed to assess whether vitamin D3 and calcium, either alone or in combination, were effective in prevention of secondary fractures.

METHODS

In a factorial-design trial, 5292 people aged 70 years or older (4481 [85%] of whom were women) who were mobile before developing a low-trauma fracture were randomly assigned 800 IU daily oral vitamin D3, 1000 mg calcium, oral vitamin D3 (800 IU per day) combined with calcium (1000 mg per day), or placebo. Participants who were recruited in 21 UK hospitals were followed up for between 24 months and 62 months. Analysis was by intention-to-treat and the primary outcome was new low-energy fractures.

FINDINGS

698 (13%) of 5292 participants had a new low-trauma fracture, 183 (26%) of which were of the hip. The incidence of new, low-trauma fractures did not differ significantly between participants allocated calcium and those who were not (331 [12.6%] of 2617 vs 367 [13.7%] of 2675; hazard ratio (HR) 0.94 [95% CI 0.81-1.09]); between participants allocated vitamin D3 and those who were not (353 [13.3%] of 2649 vs 345 [13.1%] of 2643; 1.02 [0.88-1.19]); or between those allocated combination treatment and those assigned placebo (165 [12.6%] of 1306 vs 179 [13.4%] of 1332; HR for interaction term 1.01 [0.75-1.36]). The groups did not differ in the incidence of all-new fractures, fractures confirmed by radiography, hip fractures, death, number of falls, or quality of life. By 24 months, 2886 (54.5%) of 5292 were still taking tablets, 451 (8.5%) had died, 58 (1.1%) had withdrawn, and 1897 (35.8%) had stopped taking tablets but were still providing data for at least the main outcomes. Compliance with tablets containing calcium was significantly lower (difference: 9.4% [95% CI 6.6-12.2]), partly because of gastrointestinal symptoms. However, potentially serious adverse events were rare and did not differ between groups.

INTERPRETATION

The findings do not support routine oral supplementation with calcium and vitamin D3, either alone or in combination, for the prevention of further fractures in previously mobile elderly people.

Metastatic dissemination of human malignant oral keratinocyte cell lines following orthotopic transplantation reflects response to TGF-beta 1

This study examined the behaviour of nine human malignant oral keratinocyte cell lines following orthotopic transplantation to the floor of the mouth of athymic mice. Tumourigenesis, local spread, and metastatic dissemination were correlated with known cellular responses to transforming growth factor-beta 1 (TGF-beta 1). Six of nine cell lines were tumourigenic; four of these cell lines showed local spread which was characterized by vascular and bone invasion. Metastatic spread was uncommon, with only 9% of animals with primary tumours developing metastases and these were almost exclusively found in the regional lymph nodes; there was one pulmonary metastasis and no liver deposits. Tumour cell behaviour did not reflect the clinical stage of the original tumours. Cell lines that were resistant to TGF-beta 1-induced growth inhibition were more likely to form primary tumours, exhibit local spread, and metastasize than cells that were growth-inhibited by the ligand. The data demonstrate that tumourigenicity and tumour behaviour in this orthotopic mouse model varied between cell lines and that the pattern of local invasion and metastasis was similar to that seen in human oral cancer. Furthermore, cell lines that were refractory to the growth inhibitory effects of TGF-beta 1 behaved more aggressively than cells that underwent ligand-induced cell-cycle arrest.

Functional significance of MMP-2 and MMP-9 expression by human malignant oral keratinocyte cell lines

This study examined the expression of MMP-2 and MMP-9 in normal and human malignant oral keratinocytes. The expression of pro-MMP-2 and pro-MMP-9 was heterogeneous in the malignant cell lines. Normal oral keratinocytes expressed less pro-MMP-2 and more pro-MMP-9 than their malignant counterparts. Cells that expressed high levels of both MMP-2 and MMP-9 showed the greatest degree of invasion through Matrigel in vitro compared to cells with either low or variable levels of these enzymes; normal keratinocytes were non-invasive in these conditions. The degree to which the cells invaded through Matrigel was similar to their motility in the absence of Matrigel and was not influenced by the activation of the pro-enzymes or the inhibition of enzyme activity using a chemical inhibitor of gelatinases. Cells were transplanted orthotopically to athymic mice and demonstrated a variable capacity not only to form tumours at the site of inoculation but, also, to metastasise; normal oral keratinocytes were non-tumorigenic. There was no correlation between the expression of either MMP-2 or MMP-9 and the tumorigenic/metastatic phenotype. The results emphasise the limitations of correlating in vitro and in vivo assays of tumour cell behaviour and suggest that invasion/motility in vitro may be a distinct phenotype from tumorigenicity/metastasis in vivo.

A study of the clinical characteristics of benign trigeminal sensory neuropathy

PURPOSE

The purpose of this study was to describe the clinical characteristics of a series of patients presenting with benign trigeminal sensory neuropathy.

PATIENTS AND METHODS

We conducted a retrospective analysis of the clinical and pathologic characteristics of 23 patients presenting with facial numbness of unknown etiology.

RESULTS

Patients presented with diverse medical histories but could be grouped into those with a connective tissue disorder, neurologic disease, psychologic problems, or a medical history of unknown significance. The age of the patient, the severity and distribution of the trigeminal neuropathy, and symptoms other than neuropathy closely reflected the patient's medical history. The majority of patients underwent magnetic resonance imaging, but the results did not facilitate the diagnosis of the condition or reflect the extent and severity of the symptoms. In 60% of patients, the symptoms remained unchanged during the course of the study and outcome was not influenced by medical treatment.

CONCLUSIONS

The diagnosis and management of benign trigeminal sensory neuropathy remain a significant clinical challenge.

Treatment of displaced intracapsular hip fractures with total hip arthroplasty: comparison of primary arthroplasty with early salvage arthroplasty after failed internal fixation

BACKGROUND

Closed reduction and internal fixation is the preferred initial treatment for young active patients who sustain a displaced intracapsular hip fracture. However, there is a paucity of information on the outcome in patients in whom this procedure fails and who subsequently require revision to a total hip arthroplasty. The purpose of this study was to compare a group of patients with a displaced intracapsular fracture who required early salvage total hip arthroplasty following failure of internal fixation within the first year after fracture with a group treated with primary total joint replacement for treatment of the same type of fracture.

METHODS

With use of a matched-pairs case-control design, a group of 107 patients, between the ages of sixty and eighty years, who required an early salvage total hip arthroplasty with cement following failed reduction and internal fixation of a displaced intracapsular hip fracture (Group I) was compared with an age and gender-matched group of patients who had undergone total hip arthroplasty with cement as the primary procedure for the treatment of such a fracture (Group II).

RESULTS

During the first year after the arthroplasty, there were fifty-two early complications in thirty-nine patients in Group I and twenty-two complications in fourteen patients in Group II (p < 0.05). There were significantly more superficial infections and dislocations in Group I (p < 0.05). The rate of revision beyond one year was greater and the overall prosthetic survival rate at both five and ten years postoperatively was significantly worse in Group I (log-rank test, p < 0.05). The functional outcomes at one year and at the time of final follow-up were also significantly worse in Group I.

CONCLUSIONS

Reduction and internal fixation will continue to be used as the primary treatment of displaced intracapsular fractures in many younger patients because of the benefits of preservation of the normal hip joint. However, patients should be counseled that if this method of treatment is unsuccessful and requires revision to a total hip arthroplasty with cement, the risk of early complications is higher and hip function may be poorer than if the arthroplasty had been performed as a primary procedure.

Refractures in patients at least forty-five years old. a prospective analysis of twenty-two thousand and sixty patients

BACKGROUND

Individuals who sustain a low-energy fracture are at increased risk of sustaining a subsequent low-energy fracture. The incidence of these refractures may be reduced by secondary preventative measures, although justifying such interventions and evaluating their impact is difficult without substantive evidence of the severity of the refracture risk. The aim of this study was to quantify the risk of sustaining another fracture following a low-energy fracture compared with the risk in an age and sex-matched reference population.

METHODS

During the twelve-year period between January 1988 and December 1999, all inpatient and outpatient fracture-treatment events were prospectively audited in a trauma unit that is the sole source of fracture treatment for a well-defined local catchment population. During this time, 22,060 patients at least forty-five years of age who had sustained a total of 22,494 low-energy fractures of the hip, wrist, proximal part of the humerus, or ankle were identified. All refracture events were linked to the index fracture in the database during the twelve-year period. The incidence of refracture in the cohort of patients who had sustained a previous fracture was divided by the "background" incidence of index fractures within the same local population to obtain the relative risk of refracture. Person-years at-risk methodology was used to control for the effect of the expected increase in mortality with advancing age.

RESULTS

Within the cohort, 2913 patients (13.2%) subsequently sustained a total of 3024 refractures during the twelve-year period. Patients with a previous low-energy fracture had a relative risk of 3.89 of sustaining a subsequent low-energy fracture. The relative risk was significantly increased for both sexes, but it was greater for men (relative risk = 5.55) than it was for women (relative risk = 2.94). The relative risk was 5.23 in the youngest age cohort (patients between forty-five and forty-nine years of age), and it decreased with increasing age to 1.20 in the oldest cohort (patients at least eighty-five years of age).

CONCLUSIONS

Individuals who sustain a low-energy fracture between the ages of forty-five and eighty-four years have an increased relative risk of sustaining another low-energy fracture. This increased risk was greater when the index fracture occurred earlier in life; the risk decreased with advancing age. Secondary preventative measures designed to reduce the risk of refracture following a low-energy fracture are likely to have a greater impact on younger individuals.

Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: risk factors and results of treatment

BACKGROUND

After an anterior dislocation, shoulder instability may occur with disruption of the soft-tissue or osseous restraints, leading to early redislocation. The aim of the present study was to clarify the risk factors for this complication within the first six weeks after a first-time anterior traumatic dislocation and to assess the outcome of treatment with immediate operative stabilization.

METHODS

A three-year, prospective, observational cohort study of 538 consecutive patients with a first-time anterior dislocation of the shoulder was carried out. Reassessment of shoulder function was performed at a dedicated shoulder clinic, and suspected early redislocations were assessed with additional radiographs. All medically fit patients with a confirmed acute redislocation were treated with repeat closed reduction under anesthesia. Patients with unstable reductions were treated operatively. Functional and radiographic assessment of outcome was carried out during the first year after dislocation.

RESULTS

Seventeen (3.2%) of the 538 patients sustained an early redislocation within the first week after the original dislocation. Patients at increased risk of early redislocation included those who sustained the original dislocation as the result of a high-energy injury (relative risk = 13.7), those who had a neurological deficit (relative risk = 2.0), those in whom a large rotator cuff tear occurred in conjunction with the dislocation (relative risk = 29.8), those in whom the original dislocation was associated with a fracture of the glenoid rim (relative risk = 7.0), and those who had a fracture of both the glenoid rim and the greater tuberosity (relative risk = 33.5). Following operative reconstruction, the outcome at one year after the injury was favorable in terms of function, general health, and radiographic findings. None of the patients had a redislocation or symptoms of instability at one year.

CONCLUSION

All patients who have substantial pain, a visible shoulder deformity, or restriction of movement at one week after reduction of a first-time dislocation should be evaluated with repeat radiographs to exclude a redislocation. Patients in whom this complication develops usually have either (1) severe disruption of the soft-tissue envelope due to a large rotator cuff tear or (2) disruption of the normal osseous restraints to dislocation due to either an isolated fracture of the glenoid rim or fractures of both the glenoid rim and the greater tuberosity. Early operative stabilization is justified for patients in whom the dislocation is associated with these coexisting conditions and who have evidence of gross instability.

Implant-related fractures of the femur following hip fracture surgery

BACKGROUND

Most hip fractures are treated surgically, with use of either internal fixation or prosthetic replacement of the femoral head. The presence of these implants increases the risk of a later femoral fracture in susceptible osteoporotic patients. The purpose of this study was to analyze the incidence of and risk factors for implant-related fractures of the femur after previous hip fracture surgery.

METHODS

Over a ten-year period from January 1988 to December 1997, 6230 patients (median age, eighty-two years; male:female ratio, 1247:4983) who sustained a total of 6696 hip fractures were admitted to the Edinburgh Orthopaedic Trauma Unit. Demographic information on the patients and details of the original treatment of the hip fracture were prospectively coded and entered into a trauma database. All subsequent readmissions due to a femoral fracture related to the implant were prospectively audited and extracted for the purposes of this study.

RESULTS

One hundred and forty-one patients sustained an ipsilateral fracture of the femur at a median of twenty-four weeks following the original hip fracture surgery. Survivorship analysis of the hip fracture population revealed an overall rate of subsequent femoral fracture of 2.9% at five years, which increased to 5.1% at ten years. The median age and gender distribution of the patients who sustained a subsequent femoral fracture were similar to those of the hip fracture population as a whole. Two-thirds of the fractures propagated from the tip of the implant. Analysis of the subsequent fractures according to the type of implant used to treat the original fracture revealed considerable differences in incidence. The incidence was relatively high in the patients initially treated with a Gamma nail (18.74 fractures per 1000 person-years) or a cementless hemiarthroplasty (11.72 per 1000 person-years) and was relatively low in those treated with a compression hip screw (4.46 per 1000 person-years), cannulated screws (4.50 per 1000 person-years), or a primary arthroplasty with cement (6.2 per 1000 person-years). The highest incidence of fracture was seen in the patients who had required an arthroplasty with cement as a revision procedure following failure of a primary implant (22.39 per 1000 person-years).

CONCLUSIONS

Implant-related fractures following hip fracture surgery are more common than has previously been appreciated. The risk of later ipsilateral femoral fracture is increased by the use of a Gamma nail or a cementless hemiarthroplasty to treat the original hip fracture.

Fractures of the pubic rami. Epidemiology and five-year survival

We reviewed 286 consecutive patients with a fracture of a pubic ramus. The overall incidence was 6.9/100,000/year in the total population and 25.6/100,000/year in individuals aged over 60 years. The mean age of the patients was 74.7 years and 24.5% suffered from dementia. Women were affected 4.2 times more often than men. After injury, geriatric rehabilitation was frequently required and although most surviving patients returned to their original place of residence, their level of mobility was often worse. The overall survival rates at one and five years were 86.7% and 45.6%, respectively. Multiple logistic regression analysis showed that age and dementia were the only independent significant factors to be predictive of mortality (p < 0.05). Patients with a fracture of a pubic ramus had a significantly worse survival than an age-matched cohort from the general population (log-rank test, p < 0.001), but this was better than patients with a fracture of the hip during the first year after injury, although their subsequent mortality was higher. Five years after the fracture there was no significant difference in survival between the two groups.

The coagulative and cardiorespiratory responses to reamed intramedullary nailing of isolated fractures

We measured the changes during operation in seven markers of coagulation in a prospective series of 84 patients with fractures of the tibia or femur who were undergoing reamed intramedullary nailing. All patients were also continually monitored using transoesophageal echocardiography to assess marrow embolism. In a subset of 40 patients, intraoperative cardiopulmonary function was monitored, using pulmonary and systemic arterial catheterisation. The procedure produced a significant increase in prothrombin time, activated partial thromboplastin time, the level of prothrombin fragments F1+2 and D-dimers, and a decrease in the fibrinogen level, suggesting activation of both the coagulation and fibrinolytic pathways. There was evidence of both platelet hyper-reactivity and depletion, as estimated by an increase in beta-thromboglobulin levels and a decrease in the platelet count. In the patients who had invasive monitoring there was an incremental increase in mean pulmonary arterial pressure, with the changes being greatest during insertion of the guide-wire and reaming. The change in markers of coagulation, pulmonary artery pressure and arterial oxygen partial pressures correlated with the intraoperative embolic response. Greater changes in these parameters were observed during stabilisation of pathological fractures and in those patients in whom surgery had been delayed for more than 48 hours. Seven patients with pathological fractures developed more severe hypoxic episodes during reaming, which were associated with significantly greater arterial hypoxaemia, a fall in the right ventricular ejection fraction and an increase in the mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure and the pulmonary vascular resistance index. These changes suggested that the patients had transient intraoperative right heart strain. Eight patients developed significant postoperative respiratory compromise. They all had severe intraoperative embolic responses and, in the three who had invasive monitoring, there was a significantly greater increase in pulmonary artery pressure and alveolar-arterial oxygen gradient, and a fall in the ratio of arterial partial pressure of oxygen to the inspired oxygen concentration. Operative delay, intraoperative paradoxical embolisation and the scores for the severity of the coagulative and embolic responses were predictive of the development of postoperative respiratory complications on univariate logistic regression analysis. On multivariate analysis, however, only the embolic and coagulative scores were significant independent predictors of respiratory complications.

Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur

OBJECTIVES

To compare the surgical complications and functional outcome of the Gamma nail intramedullary fixation device versus the Richards sliding hip screw and plate device in intertrochanteric femoral fractures.

DESIGN

A prospective, randomised controlled clinical trial with observer blinding.

SETTING

A regional teaching hospital in the United Kingdom.

PATIENTS

All patients admitted from the local population with intertrochanteric fractured femurs were included. There were 400 patients entered into the study and 399 followed-up to one year or death.

INTERVENTION

The devices were assigned by randomization to either a short-type Gamma nail (203 patients) or a Richard's-type sliding hip screw and plate (197 patients).

MAIN OUTCOME MEASUREMENTS

The main surgical outcome measurements were fixation failure and reoperation. A functional outcome of pain, mobility status, and range of movement were assessed until one year.

RESULTS

The requirement for revision in the Gamma nail group was twelve (6%); for Richard's group, eight (4%). This was not statistically different (p = 0.29; odds ratio, 1.48 [0.59-3.7]). A subcapital femoral fracture occurred in the Richard's group. Femoral shaft fractures occurred with four in the Gamma nail group (2%) and none in the Richard's group (p = 0.13). Three required revision to another implant. Lag-screw cut-out occurred in eight patients in the gamma nail group (4%) and four in the Richard's group (2%). This was not statistically significant (p = 0.37; odds ratio, 2.29 [0.6-9.0]). The development of other postoperative complications was the same in both groups. There was no difference between the two groups in terms of early or long-term functional status at one year.

CONCLUSIONS

The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications. Routine use of the Gamma nail in this type of fracture cannot be recommended over the current standard treatment of dynamic hip screw and plate.