Multisectoral approach to address Female Genital Mutilation: a case study from Portugal

Issue

Female genital mutilation (FGM) comprises all procedures that injury female genital organs for non-medical reasons, with several health impacts. Due to global migration, FGM has been increasingly recognised as a healthcare issue in Europe, affecting nearly 1 million women. In Portugal it is estimated that 5483 migrant women have undergone FGM in the Lisbon region. Intervention is required to tackle this issue.

Description

Portugal launched the “Healthy Practices: End of FGM”, a multiagency project targeting Lisbon and Tagus Valley region. Project implementation started in Nov 2018 at 5 local public health units (PHU) and was scaled-up to 5 more in Feb 2020. Project comprises 3 main axes: 1) inclusion in public policy instruments; 2) professionals’ education and awareness; and 3) community intervention. We describe inclusion of FGM in public policy, professionals training and changes in FGM recording before and after intervention.

Results

Between 2018-2022, inclusion of FGM in municipalities’ migration policies doubled. Between 2019-2021, 110 training sessions (n = 1722 professionals) were promoted. During pandemic years, only 344 (2020) and 202 (2021) were trained. Raising awareness and empowerment to risk communities happened mainly through local/online open sessions, workshops, flyer distribution, video projections. These occurred in all 10 PHU, mostly through partnerships with Non-Governmental Organizations and municipalities. According to the Portuguese Health Records, until 2018 there were only 300 women registered with FGM. Between 2019-2021, 363 more were added.

Lessons

The multisectoral approach allowed PHU professionals to collaborate directly with external organizations from different society sectors. COVID-19 pandemic posed a challenge to implementation, especially in the community intervention axis. Notification numbers increased after interventions, though causality could not be established and impact evaluation is yet to be performed.

Key messages

• Multisectoral projects for FGM intervention have specific implementation challenges, including how to justify and evaluate them, that must be considered in each setting.

• Training health professionals might increase identification and notification of FGM, but the impact in preventing FGM in the Portuguese reality is still largely unknown.

What do future public health doctors know about the One Health concept in Portugal?

Background

The One Health (OH) approach brings together a transdisciplinary collaboration between human, animal, and environmental health, to tackle emerging zoonotic diseases, antimicrobial resistance, and food safety. Therefore, incorporating of OH principles in the education of health care providers is fundamental.

Methods

To assess OH knowledge, attitudes and practices (KAP), an anonymous, multiple-choice, online self-administered survey was sent to 1st year Portuguese Public Health Medical Residents (PPHMR), during an online congress targeted to them. A descriptive analysis was performed.

Results

A 50.0% response rate was obtained out of the 42 PPHMR attendees. Only 33.3% were familiar with OH concept; 57,1% had heard of it but were not aware of its meaning, and 9.5% had never heard of it. Concerningly, 9,5% believed zoonosis were diseases transmitted between animals and 42.9% considered that “antimicrobial resistance” is applied to antibiotics only. Regarding major zoonosis, etiologic agents were not recognized for Cryptosporidiosis (47.6%), Echinococcosis (42.9%), Toxoplasmosis and Leptospirosis (38.1%), Dermatophytosis (33.3%), Rabies (28.6%), Borreliosis/Brucellosis (23.8%). Half (52.4%) were unaware of the transmission route of Brucellosis/Dermatophytosis, followed by Leptospirosis (38.1%), Toxoplasmosis (28.6%) and Borreliosis/Rabies (23.8%). Remarkably, all participants showed willingness to be informed on OH issues and agreed that prevention and speed of intervention would be higher with greater collaboration between health technicians. About education towards OH throughout their medical curricula, 61.9% classified it as low, 23.8% as absent, 14.3% as sufficient and none classified it as adequate or very adequate.

Conclusions

This is the first study assessing KAP regarding the OH concept among PPHMR. Results highlight the need to bring OH to the Portuguese medical schools’ agenda to better prepare the next generation of PPHMR to the emerging health crisis.

Key messages

• Despite the interest shown by 1st year Portuguese Public Health Medical Residents concerning One Health, a general lack of knowledge on the topic was found.

• The majority qualified as insufficient their training on this subject, highlighting the need for medical schools to improve education and raise awareness regarding this transdisciplinary approach.

Femoral Cortical/Cancellous Bone Related to Age

The femoral cancellous/cortical relationship with age has been determined in 53 dissected femoral specimens. By means of computed tomography (CT) values related to bone density and mass were assessed in the femoral head, neck, trochanter, shaft, and condyles. In the neck and trochanter separate measures were made in cortical and cancellous bone. The results were analyzed by means of correlation and regression analyses. There were significant negative linear correlations between the CT measures and age for all measures except for the isolated cancellous measures in the femoral neck and trochanter. Our results indicate that in the femoral neck and trochanter the cortical bone mass constitutes a substantial amount of the total bone mass. We conclude that, since bone strength to a large part is a function of the total bone mass, loss of cortical bone may be more important than loss of cancellous bone.

Axial and Appendicular Bone Mineral Content Determined by Computed Tomography; Relationship to Age and Body Size in Males

Bone density and mass related values were determined in femoral condyles and in the second lumbar vertebra in males of middle age. A poor agreement was found between measurements in the two locations. The measurements were compared with age and body size by means of correlation analysis and multiple regression analysis. There was a significant linear relationship between lumbar measures and age (β coefficient −0.61 and −0.75) while the relationship with age for the femoral measures was less (β −0.36 and −0.45). For all measurements there was a poor correlation with body size (weight, length and surface area). Bone mineral content measurements in the lumbar and appendicular skeleton have different clinical implications. When selecting a method for estimating the bone mineral content careful attention must be paid to what type of information is wanted and whether the method is adequate for that particular purpose.

Assessment of Bone Mineral Content in the Internal Bone Volume

A method for assessing values related to bone density and mass is described. Mean attenuation and pixel area are measured in pixels selected on the basis of CT units. The method is to a large extent computerized and not dependent on manual positioning or outlining of a region of interest. Because it is not dependent on a comparatively large volume of homogeneous bone it can be used to make assessments even in very heterogeneous bones including cortical bone. The method is adaptable for measurement in all parts of the skeleton and values related to both bone density (DRV) and bone mass (MRV) are derived. The measurements in the femoral condyles were shown to have a precision of approximately 0.25 to 0.30 Z-score units (standard deviation of the measurements expressed in Z-score units). The agreement between chemically analyzed calcium density (weight of calcium per volume) and DRV was little less than 0.50 Z-scores and 0.30 Z-scores for the chemically determined calcium mass and the MRV. The agreement with mechanical bone strength was 0.78 Z-scores for DRV and 0.64 for the MRV. Altering scan parameters or measuring approaches gave systematic differences in the measurements. There were, however, good linear correlations between the measurements which show that these different measuring approaches essentially gave identical measurements.

Cemented Lubinus and Furlog total hip endoprosthesis: a 12-year follow-up study of 175 hips comparing the cementing technique

We analyzed 175 total hip replacements with cemented Lubinus and Furlong arthroplasties in 164 patients with a median age of 65 (32-80) years and followed them for 12 years to evaluate and compare the efficacy of total hip prosthesis designs. Survival analysis was combined with an analysis of radiological findings and a study of functional outcome of the patients. The 12-year survival of Furlong arthroplasty in patients of 60 years of age and older was O.85 (95% CI 1.00-0.52). The survival of Lubinus arthroplasty in patients younger than 60 years of age was 0.70 (0.91-0.48), while the survival in older patients was 0.75 (0.89-0.61). The 12-year survival of well-cemented Lubinus prosthesis was 0.91 (1.00-0.79), indicating the importance of the cementing technique. The survival of the cups was marginally better than that of the stems. In the 12-year follow-up study, the clinical state and function varied from hips ready for revision to hips where a continuously long survival could be predicted. Harris hip score did not differentiate between patients who had intact and loose components. We conclude that cemented arthroplasty affords a notable alternative with satisfactory long-term survival and function. The better survival of cemented cup than the stem may be utilized as a basis for "reverse" hybrid arthroplasty. Adequate long-term follow-up of all arthroplasties as a quality maintenance and to prevent difficult revisions is a major challenge.

Impaction bone grafting in revision hip surgery. A high incidence of complications

We have reviewed retrospectively 68 revisions of the femoral component in arthroplasties of the hip in 65 patients, using impaction bone grafting, at a median of three years (1 month to 6 years). We employed the cemented Exeter X-Change technique in 36 patients and the uncemented Bi-Metric allografting method in 32. The 37 bone defects were grade 3 or grade 4 on the Endo-Klinik classification. The Mayo hip score improved from a mean of 32 (SD +/- 18) to 62 (SD +/- 15). Most (25) of the 34 complications occurred in grade-3 and grade-4 defects; nine were intraoperative diaphyseal fractures and eight fractures of the greater trochanter. All the fractures united. The risk of intraoperative fracture was prevented by supporting the bone with wires in 16 hips, with reinforcement mesh in 18 and by a plate in six. Early migration of the stem of more than 10 mm during the first year indicated rotational instability; it occurred in three cases. In difficult revision cases with large defects of the femoral bone, bone-impaction techniques carry a high risk of complications.

Impaction bone grafting in revision hip surgery

We have reviewed retrospectively 68 revisions of the femoral component in arthroplasties of the hip in 65 patients, using impaction bone grafting, at a median of three years (1 month to 6 years). We employed the cemented Exeter X-Change technique in 36 patients and the uncemented Bi-Metric allografting method in 32. The 37 bone defects were grade 3 or grade 4 on the Endo-Klinik classification.

The Mayo hip score improved from a mean of 32 (sd ± 18) to 62 (sd ± 15). Most (25) of the 34 complications occurred in grade-3 and grade-4 defects; nine were intraoperative diaphyseal fractures and eight fractures of the greater trochanter. All the fractures united.

The risk of intraoperative fracture was prevented by supporting the bone with wires in 16 hips, with reinforcement mesh in 18 and by a plate in six. Early migration of the stem of more than 10 mm during the first year indicated rotational instability; it occurred in three cases.

In difficult revision cases with large defects of the femoral bone, bone-impaction techniques carry a high risk of complications.

Mutational analysis of the HGO gene in Finnish alkaptonuria patients

Alkaptonuria (AKU), the prototypic inborn error of metabolism, has recently been shown to be caused by loss of function mutations in the homogentisate-1,2-dioxygenase gene (HGO). So far 17 mutations have been characterised in AKU patients of different ethnic origin. We describe three novel mutations (R58fs, R330S, and H371R) and one common AKU mutation (M368V), detected by mutational and polymorphism analysis of the HGO gene in five Finnish AKU pedigrees. The three novel AKU mutations are most likely specific for the Finnish population and have originated recently.

A prospective study of teleconferencing for orthopaedic consultations

We carried out a prospective study of teleconsulting in orthopaedics. A commercial videoconferencing system was connected by three ISDN lines between the Satakunta Central Hospital in Pori and the Orton Orthopaedic Hospital in Helsinki, 240 km away. A document camera was used to transfer radiographic images and paper documents. Twenty-nine patients who needed an orthopaedic consultation were studied over three months. They were examined by a surgeon in Pori with the aid of teleconferencing and again later in a traditional, face-to-face appointment in Helsinki. Patients and doctors completed questionnaires after the consultations. Technically, the videoconferencing system functioned reliably and the quality of the video was judged to be good. Twenty patients (69%) would not have needed to travel for a face-to-face appointment, because the teleconsultation afforded a definite treatment decision. The orthopaedic surgeons considered all the treatment decisions arising from the teleconsultation good, except in one case which was considered satisfactory. The quality of the radiographic images transferred with the document camera was good or very good in 17 cases and satisfactory in three cases. None of the patients had experienced videoconferencing before; 87% of them thought that teleconsultation was a good or very good method and the rest felt that it was satisfactory. All patients wanted to participate in teleconsultations again and most would have recommended it to other patients.

Internally fixed femoral neck fractures. Early prediction of failure in 203 elderly patients with displaced fractures

After internal fixation of a femoral neck fracture, 3 months is the critical time for planning rehabilitation of the patient. Most failures in the elderly occur within this time. In a series of 165 patients, we followed 127 women and 38 men with a median age of 81 (63-97) years from an examination at 3 months to reoperation or survival of the hip. 36 patients had radiographic signs of disturbed healing at the 3-month follow-up--change in fracture position by 10 mm, change in screw position by 5%, backing of the screws by 20 mm, or perforation of the femoral head by the screw. These signs had a high association with local complications and need for a later reoperation. High age and male sex increased this association. Signs of impaired healing made nonunion likely, but did not predict late segmental collapse of the femoral head. Patients with signs of disturbed healing and those closest to them should be informed about the value of early check-ups in case of pain and impaired function.

Recovery of sciatic nerve injuries in association with total hip arthroplasty in 27 patients

We analyzed 27 sciatic nerve injuries associated with total hip arthroplasty (THA). The patients were 23 women and 4 men, and their median age was 55 years (range, 28-75 years). In 1987 to 1995, 4,339 THAs were performed. Primary arthroplasties accounted for 3,471 and 868 were revisions. Nine patients had developmental dysplasia of the hip. Six operations were revisions. Radiologic lengthening was median 1.4 cm (range, -1 to 4.1 cm); in 8 cases, lengthening was greater than 2 cm. The median follow-up period was 58 months (range, 24-110 months). Eight patients recovered fully, the recovery of 7 patients was fair, and 12 patients had a considerable permanent disability. The risk of nerve injury was not related to the extent of lengthening. The recovery of the nerve injury was only weakly correlated to its primary postoperative extent. The sciatic nerve injury rate was 0.6%.

Treatment of periprosthetic fractures in association with total hip arthroplasty--a retrospective comparison between revision stem and plate fixation

BACKGROUND AND AIMS

In periprosthetic fracture associated with hip arthroplasty, no consensus exists about the use of plate fixation or revision stem except for cases where the stem is loose in a young patient and a revision is made. The aim of the present retrospective study was to compare two commonly used alternatives for treatment of the fracture--revision arthroplasty and plate fixation.

MATERIAL AND METHODS

Seventy-five fractures associated with total hip arthroplasty were treated with revision arthroplasty (N = 40) or compression plate fixation (N = 35). Twenty-one fractures were intraoperative and 54 were postoperative. In revision arthroplasty, cemented (N = 11) and porous-coated (N = 29) stems were sued. Autologous bone grafts were used in 15 revision arthroplasties and 20 plate fixations. The follow-up time was median 20 months (range 12-96 months).

RESULTS

Bone grafting at the time of fracture treatment had no significant effect on fracture healing in the present setting. One patient in both groups was operated secondarily because of fracture instability. Five nonunions in the former and 9 nonunions in the latter group were treated by repeated revision and bone graft. In two revision arthroplasties and nine cases with plate fixation, a secondary bone grafting operation was performed for delayed union. In all, 20 secondary operations were needed after prosthesis stem revision and 27 secondary operations after plate fixation (p = 0.014). The need for reoperations was similar in fractures at different levels of the femur. Fracture healing was finally obtained in 39 revision arthroplasties and 34 cases with plate fixation during the follow-up period.

CONCLUSIONS

Cases where the prosthesis stem is stable, where its removal would include great risks and, where the biomechanical conditions are optimal, are best treated with plate fixation. In cases where the stem is loose and where a choice is possible, stem revision is preferable to plate fixation.

Biases in a randomized comparison of three types of screw fixation in displaced femoral neck fractures

We studied fixation of displaced femoral neck fractures prospectively in a randomized multicenter study, comparing 2 Olmed screws, 2 Tronzo screws and 3 Ullevaal hip screws. The study population consisted of 482 women and 125 men, of whom 432 women and 100 men were older than 65 years of age. Their median age was 80 (54-97) years. Despite agreement on criteria, the rates of reoperations for pain and failure--salvage (prosthesis replacement) and other reoperations (removal of implant)--differed significantly between the 3 hospitals regardless of type of fixation. In total, the percentages of salvage operations were: Olmed screw 17/175, Tronzo 17/130 and Ullevaal screw 11/302 (n.s.); the percentages of other reoperations were 11, 6 and 13, respectively (n.s.). In the whole series, the 2-year rate of salvage operations was 14%. No differences between the implants were found in patients older than 65 years of age. We conclude that an agreed, common definition of a hard end-point (reoperation) does not ensure comparability of results, because of differences in clinical decision making.

Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw

OBJECTIVE

To compare the results after operative treatment of unstable per- and subtrochanteric fractures with the Gamma nail, compression hip screw (CHS), or dynamic hip screw with a laterally mounted trochanteric stabilizing plate (DHS/TSP).

DESIGN

Prospective.

PATIENTS

One hundred seventy patients with unstable trochanteric femoral fractures surviving six months after operation. Eighty-five patients were randomized to treatment with the Gamma nail (n = 50, Gamma group) or the compression hip screw (n = 35, CHS group) and compared with a consecutive series of eighty-five patients operated with the dynamic hip screw with a laterally mounted trochanteric stabilizing plate (DHS/TSP group)

MAIN OUTCOME MEASUREMENTS

Radiographs were analyzed for fracture classification, evaluation of fracture reduction, implant positioning, later fracture dislocation, and other complications. Pre- and postoperative functional status of the patients were recorded, with a minimum of six months follow-up.

RESULTS

Eighteen percent of the patients in the Gamma group, 34 percent in the CHS group, and 9 percent in the DHS/TSP group suffered significant secondary fracture dislocation during the six months follow-up, leading to a varus malunion, lag screw cutout, or excessive lag screw sliding with medialization of the distal fracture fragment. Two patients (4.0 percent) in the Gamma group suffered an implant-related femoral fracture below the nail, and one had a deep infection. The reoperation rates were 8.0 percent in the Gamma group, 2.9 percent in the CHS group, and 5.9 percent in the DHS/TSP group. All but one fracture in the Gamma and CHS groups and two fractures in the DHS/TSP group healed within six months. Approximately three-fourths of the patients had returned to their preoperative walking ability after six months, with a trend toward better functional outcome in the DHS/TSP group. Use of a TSP reduced the secondary lag screw sliding as compared with the conventional CHS, without affecting fracture healing.

CONCLUSION

The TSP may be an aid in the treatment of these difficult fractures because the problem with femoral shaft fractures using the Gamma nail is avoided and the medialization of the distal fracture fragment frequently associated with the CHS is prevented.

Improved diagnostic assessment of major depression in psychiatric outpatient care in Finland

The accuracy of diagnosis of major depression by psychiatrists, psychiatric residents, and other physicians in outpatient psychiatric care settings in Finland was examined. A total of 232 patients who visited four mental health centers in the hospital district of Satakunta during three years (1989, 1992, and 1995) were retrospectively given a diagnosis of first-episode major depression by researchers, based on chart reviews. These diagnoses were compared with those made by the evaluating clinicians. Accurate diagnosis was associated with the specialty of the physician and the location of the mental health center. Recognition of major depression significantly improved over the time period, which could be attributed to educational efforts, increasing familiarity with DSM-III-R criteria, and use of new antidepressants.

Concurrent ipsilateral fractures of the hip and shaft of the femur. A systematic review of 722 cases

BACKGROUND AND AIMS

Ipsilateral fracture of the hip and femoral shaft is encountered in high-energy trauma, and warrants special diagnostic and therapeutic considerations, which are not available in any single report. Therefore, a meta-analysis was performed.

MATERIAL AND METHODS

Seven hundred and twenty-two cases of concurrent, ipsilateral fractures in the hip and femoral shaft reported in 65 publications were reviewed. This high-energy injury combination was rare in children, the median age of the patients being 34 years (range 3-76 years). 78% of them were men, 44% were multiply injured. Concurrent hip fractures were reported in 0.8 to 8.6% of all femoral shaft fractures.

RESULTS

The trauma force was found to cause buckling of the femur and shearing of the femoral neck. Hip fractures, divided into 5 subtypes, had the following distributions: subcapital-2%, midcervical-21%, basicervical-39%, pertrochanteric-14% and intertrochanteric-24%. The diagnosis of the hip fracture was delayed in 30% of the cases, but it healed in 99% with most operative methods with no deep infections. The average rate of avascular necrosis of the femoral head was 5.1%. Plate fixation of the shaft fracture was complicated by deep infection in 6.1%, by non-union in 9.8% and yielded a poor outcome in 11.0% of the cases. The respective figures for unlocked intramedullary nailing were 2.7%, 2.7% and 6.8% and for locked nailing 0%, 0% and 0%, respectively. Fixation of the hip fracture was bound with more complications (reoperations and malunions) in combination with nailing than plate fixation.

CONCLUSIONS

Early diagnosis of all injuries and operative treatment of all fracture components are the key factors in reducing complications and improving the outcome in ipsilateral hip and shaft fractures. Locked nails and hip screws yield improved results compared with plates and unlocked nails combined with hip screws. Cephalo-medullary nails have yielded results similar to the first-generation locked nails.

Experimental telemedicine in orthopaedics

There have so far been few telemedical applications in orthopaedics. This experiment involved clinicians in three different locations, two in Helsinki and the third in Tampere, consulting one another simultaneously. We used an ATM network to transfer X-ray pictures, digitized by a 12-bit CCD scanner and archived in a central image server. The consultations between the clinicians and the examination of the patient were transmitted by a videoconferencing system using the ISDN. We found that telemedicine offers new possibilities in orthopaedics, for clinical work, for training and for research.

Accuracy of pedicle screw insertion: a prospective CT study in 30 low back patients

A prospective study of the accuracy of titanium pedicle screw placement in 30 low back operations was performed. The postoperative plain radiographs and CT reformation images were evaluated by two independent radiologists. Thirty-two out of 152 screws (21%) perforated the pedicle cortex. One-tenth of the perforations was detected with conventional radiography. In ten patients (33%) all the screws were located within the pedicle. The clinical significance of this study lies in the finding that pedicle perforations are more frequent than is generally believed and that, in spite of the many malplacements, no screw that perforated by less than 4.0 mm caused neurological problems. Only one nerve root lesion was detected.

Fixation of displaced femoral neck fractures with a sliding screw plate and a cancellous screw or two Olmed screws. A prospective, randomized study of 225 elderly patients with a 3-year follow-up

BACKGROUND AND AIMS

To analyse the importance of fixation method in displaced femoral neck fractures and to identify factors predictive of failure of the fixation.

MATERIAL AND METHODS

Two hundred and twenty-five patients were included in a prospective, randomised study and operated on for a displaced, subcapital fracture of the femoral neck with either a sliding screw plate and a parallel cancellous screw (SSP), or two Olmed screws. The median follow-up time was 39 (22-51) months, excluding reoperated and dead patients.

RESULTS AND CONCLUSIONS

Operation and anaesthesia time was considerably longer for the SSP system. The risk of failure was significantly increased (odds ratio 6.6) for patients operated with SSP outside ordinary working time. Poor reduction was recognized as a risk factor of failure for both types of fixation (odds ratio 3.1). The rate of reoperation within 3 months was 18.5% in the SSP group and 9.4% in the Olmed screw group. The rates of nonunion were 6.2% and 8.5%, respectively. The rates of late segmental collapse, 18.0% and 19.5% of all united fractures, respectively, decreased with increasing age (odds ratio 0.88). Salvage operations (replacement with bipolar or total hip prosthesis) were made in 30.6% and 26.5% of the cases, and the total rates of reoperation were 37.0% and 29.1%, respectively. We conclude that both treatment methods result in an unacceptably high rate of failures and reoperations, and that alternative treatment, prosthesis replacement, should be considered in selected cases.

Anomalous nerve anatomy at the wrist?

BACKGROUND AND AIMS

The common course of the ulnar and median nerve in the carpal tunnel has been described previously on two occasions. The aim of the study was to explain the cause of two main nerve trunks in the carpal tunnel found at an operation.

MATERIAL AND METHODS

A patient was treated with open reduction and internal fixation for a volar Barton's fracture of the distal radius. Later, compression syndrome of the ulnar and median nerves developed. At operation, two nerves were found in the carpal tunnel. Electroneuromyography (ENMG) and magnetic resonance imaging (MRI) confirmed a divided median nerve.

RESULT AND CONCLUSION

No anomaly of the ulnar nerve was confirmed. Deviation from the common clinical and ENMG picture of the carpal tunnel syndrome should result in thorough evaluation of possible anomalous nerve anatomy at the wrist. When at operation findings are suspicious of anomalous anatomy of the median or ulnar nerves in the carpal tunnel, Guyon's canal should also be explored to clarify the anatomy of the nerves. In cases with previous carpal collapse or other space occupying lesions we recommend division of the whole transverse carpal ligament in connection with a volar osteosynthesis, because the operative trauma may cause elevation of pressure in both the carpal and Guyon's canals.

Concurrent ipsilateral fractures of the hip and femoral shaft: a meta-analysis of 659 cases

659 cases of concurrent, ipsilateral fractures in the hip and femoral shaft reported in 59 studies were analyzed. The causes were a road traffic accident in 78% and other types of high-energy traumas in 13% of the patients. This injury combination was rare in children. The median age was 34 years. 78% of the patients were men. One-third had multiple injuries, one-half had injuries of the ipsilateral knee and one-half had other lower limb injuries. The femoral neck fractures were most often basilar and the reported rate of avascular necrosis was 3%. The trochanteric fractures were intertrochanteric transverse, and seldom comminuted. The important factors in reducing morbidity were an early diagnosis of all injuries and efficient treatment of the shaft fractures. Locked intramedullary nails yielded results which were superior to combinations of plates or unlocked nails and separate hip screws. Reconstruction nails (cephalomedullary nails) gave results equal to those of customary locked nails and separate hip screws. The rate of healing of the hip fracture was over 99%, the treatment of the shaft fracture being of main importance for the outcome.

A locked hip screw-intramedullary nail (cephalomedullary nail) for the treatment of fractures of the proximal part of the femur combined with fractures of the femoral shaft

Twenty-seven patients with complex femoral fractures (combined shaft and proximal femoral fractures) were treated with a modified Grosse-Kempf slotted locking nail (cephalomedullary nail), wherein two screws were inserted in the hip. Four types of complex, multifocal femoral fractures were represented in the series. Eleven of the femoral shaft fractures were secondary to a previous, internally fixed, not yet united hip fracture (type I). Ten comminuted peritrochanteric fractures occurred in normal bone (type II). Three similar fractures were pathologic because of metastasis. Two patients had an ipsilateral fracture of the femoral shaft and the trochanteric area (type III), and one of the shaft and the femoral neck (type IV). Locking was made static in 24 cases. Additional cerclage wiring was used in three type II fractures. Five complications were as follows: one cutting out of a screw in the femoral head, two fractures of the nail, one deep venous thrombosis, and one wound hematoma. Reoperations were two salvage operations using a new nail and one evacuation of hematoma. One patient with multiple injuries and four elderly patients died within 2 months. Eighteen patients with fractures in normal bone were followed for a median of 20 (6 to 37) months. All fractures united. Two nails were removed. The end result was excellent in ten patients, good in seven, and fair in one (2-cm shortening and 20-degree external rotation). We conclude that a locked intramedullary construct with locking screws in femoral neck and distal femur controls a complex fracture situation well.

The repair of a ruptured deltoid ligament is not necessary in ankle fractures

We randomised 50 patients with ankle fractures of Weber types B and C and a ruptured deltoid ligament treated by open reduction and internal fixation to two treatment groups to examine the influence of the repair of a ruptured deltoid ligament. No differences were found except for a longer duration of surgery in the repair group. Our findings suggest that a ruptured deltoid ligament can be left unexplored without any effect either on early mobilisation or on the long-term result.

The repair of a ruptured deltoid ligament is not necessary in ankle fractures

We randomised 50 patients with ankle fractures of Weber types B and C and a ruptured deltoid ligament treated by open reduction and internal fixation to two treatment groups to examine the influence of the repair of a ruptured deltoid ligament. No differences were found except for a longer duration of surgery in the repair group. Our findings suggest that a ruptured deltoid ligament can be left unexplored without any effect either on early mobilisation or on the long-term result.

Bending strength of the femur in relation to non-invasive bone mineral assessment

To analyze the importance of bone mineral for the strength of the distal diaphyseal femur, we studied 14 distal cadaver femora by quantitative computed tomography, (QCT) dual energy X-ray (DXA) absorptiometry and three-point bending. The femora were retrieved at autopsy from 10 male and 4 female donors aged median 74 yr (range 59-92 yr). Significant correlations were found between three bone mineral mass related parameters--QCT bone mass (density x slice area), DXA mineral density (BMD) and content (BMC)--and mechanical parameters. Second area moment equivalents correlated significantly with the mechanical properties of the distal femur. QCT density did not show the same high correlations. The results indicate that the structural strength of diaphyseal bone is determined more by its geometry than mineral density. Assessment of bone mass by QCT or DXA may become important not only for assessment of fracture risk but also for planning of internal fixation in the treatment of osteporotic fractures. Further studies are required to investigate the clinical importance of these observations.

Pairwise strength relationships of cortical and cancellous bone in human femur: an autopsy study

To analyze the mechanical properties of cortical and cancellous bone in the femur and relate them to bone mineral, we retrieved 14 pairs of femurs from elderly subjects at autopsy. Bone mineral was measured by quantitative single-energy computed tomography. Significant associations were found between two types of cortical bone mechanical tests, three-point bending and pull-out of screw, one performed on the right and the other on the left femur. Similarly, pairwise associations were found between the mechanical tests of cancellous bone, punch and cube compression, one performed on the right and the other on the left femur. Also, all mechanical tests correlated with bone mineral as determined by quantitative single-energy computed tomography. In general, bone mass measures correlated better with bone strength than did bone density measures. However, the cortical and cancellous bone mechanical properties were not interrelated, which suggests a separate regulation of the strength of these two types of bone. Bone mineral may not only have importance for the occurrence of fractures; it should be considered as an important factor in the fixation of fragile bone.

Ruptured pectoralis major tendon. A case report on delayed repair with muscle advancement

A total rupture at the humeral insertion of the pectoralis major tendon was repaired 3 months after the injury by sutures through 3 pairs of drill holes in the crest of the greater tubercle. To unload the sutures and to facilitate early mobilization, the muscle was advanced by fascial detachment in the medial-inferior origin of the muscle. Full mobility was achieved in 1 month and full activity was allowed 1 month later.

Operative treatment as a part of the comprehensive care for patients with injuries of the thoracolumbar spine. A review

In a total appraisal, the advantages and drawbacks of operative decompression and stabilisation of the injured thoracolumbar spine should be evaluated in the treatment of a paraplegic patient and of a patient without neural damage. Operative treatment may be advantageous independent of its effect on the neural damage. Only a few studies allow direct comparison between operative and conservative treatment. Some studies are only of historical value. Today, a general operative policy is to use Harrington rods in the thoracic spine. For injuries caudal to the 9th thoracic vertebra and for those with injuries in the lumbar spine, internal fixators with transpedicular screws are used. Anterior decompression and stabilisation are also warranted in some cases. New implants are continuously being developed, e.g. implants which combine the advantages of hooks and pedicular screws. No study shows conclusively that operative treatment improves the neurological status compared with conservative care. Conservative and operative treatment may both have particular complications. It appears that neurological deterioration is more likely to occur after conservative treatment, while complications related to wound healing and from the implants burden the operative alternative. Mobilisation is quicker and easier after operative treatment, improving psychological and social rehabilitation. Also, these patients experience less in the way of chronic back pain. A high level of expertise is required for operative treatment and this illustrates the general need for the centralisation of the treatment of these relatively rare and severe injuries.

Gamma nail vs compression screw for trochanteric femoral fractures. 15 reoperations in a prospective, randomized study of 378 patients

A total of 378 trochanteric and subtrochanteric femoral fractures were randomized to treatment with Gamma nail (177) or Hip Compression Screw (HCS) (201). After a median follow-up time of 17 (10-27) months, 15 patients needed reoperations; 13 had been treated with Gamma nail and 2 with HCS. 10 patients, all treated with Gamma nail, were reoperated because of a femoral shaft fracture. 5 of these fractures occurred 8 (4-10) days postoperatively and were related to intraoperative complications. The other 5 shaft fractures occurred a median of 2 (1-3) months postoperatively after falls, and may be related to stress concentration at the tip of the solid nail. The lag screw cut out or penetrated the femoral head in 5 patients, 3 of them treated with Gamma nail and 2 with HCS.

Aneuploidy in benign tumors and nonneoplastic lesions of musculoskeletal tissues

BACKGROUND

Aneuploidy in DNA flow cytometry (FCM) of musculoskeletal tumors is generally considered to be a sign of malignancy. Previously, giant cell tumor of the bone has been reported to contain aneuploid (near-diploid) DNA stemlines. Otherwise, only spordic cases have been reported. The authors wanted to study the relationships among DNA FCM, histology, and clinical course of nonmalignant musculoskeletal lesions.

METHODS

Twenty-eight histologically benign tumors and seven nonneoplastic lesions were subjected to DNA FCM: After tissue preparation mechanically and with ribonuclease and trypsin, the isolated nuclei were stained with propidium iodine using chicken and rainbow trout erythrocytes as controls. In the DNA FCM histograms, ploidy and cell cycle fractions were determined using a computerized mathematical model. The histologic diagnoses were made without knowledge of the DNA FCM results.

RESULTS

Aneuploidy was found in eight lesions. A shoulder in the diploid peak, suggesting a diploid and a near-diploid population, was found in DNA histograms of a condensing osteitis of the clavicle (a benign inflammatory process) and of a giant cell tumor of bone. The latter lesion also had a tetraploid population. Six benign tumors--two enchondromas, one osteochondroma, one subcutaneous and one intramuscular lipoma, and a calcifying aponeurotic fibroma--showed clear aneuploidy with separate peaks. The S-phase fraction was less than 10% in all cases. The highest aneuploid population, DNA index = 1.70, in a subcutaneous lipoma, was small, with an undetectable S phase. Despite nonradical operations in seven lesions, no recurrences were observed during a median follow-up of 49 months (range, 28-73 months).

CONCLUSIONS

Small aneuploid populations with low DNA synthetic activity may be compatible with a benign histologic picture and uneventful clinical course of the musculoskeletal lesion.

Retention of distal femoral osteotomy fixed with a AO condylar plate and Grosse-Kempf locked nail in relation to bone mineral in cadavers

On the basis of previous studies showing good correlations between the structural strength of the femur and bone mass as assessed by single energy quantitative computed tomography, this study was scheduled to analyze the mode of failure of an oblique osteotomy in the distal femur in geriatric cadavers stabilized by an AO condylar plate and Grosse-Kempf locked intramedullary nail in axial eccentric loads and to relate the mode of failure to bone mineral content. A pilot study of two pairs of osteotomized, internally fixed femora were loaded axially and the loads correlated with bone mineral content. These correlations were used to calculate estimated failure load in 12 pairs of osteotomized femora (12 plated and 12 nailed specimens) which then were sustained to a cyclic eccentric axial load of 50% of the estimated failure load. The failure patterns in the two groups were different. Fixation failure occurred in all specimens in the plated group at the site of the osteotomy, while in the nailed group the fixation failures in 50% of the specimens were unrelated to the site of the osteotomy. The study suggests that locked intramedullary nailing of a distal femoral fracture in osteoporotic bone gives more secure fracture retention than fixation with a 95 degrees AO/ASIF condylar plate. Furthermore, it shows that bone mineral assessment by densitometric methods can be used to predict the mechanical strength of a bone/implant construct.

Implant/bone constructs in femoral neck osteotomy. An autopsy study

Previous studies have suggested that three rather than two screws may give better results in the treatment of femoral neck fractures. In the present study, the strength of various screw/bone constructs in femoral neck osteotomy was analyzed. Transverse osteotomies on 65 cadaver femora were fixed with two or three screws of two types: one with a shank diameter of 6 mm and thread diameter of 8 mm, and a prototype screw with equal shank and thread diameter of 7 mm. The femoral heads were subjected to static and cyclic loads in the one-legged stance position. Single-energy quantitative computed tomography measurements were correlated to load. The two experimental models resulted in different patterns of failure of the bone/implant constructs, otherwise the results were similar. Three of the prototype screws gave the strongest construct, while two of the other screw type were stronger than three. The explanations for the diverging properties of the different bone/implant constructs may be that large threads destroy too much of the bone trabeculae, and that screw threads larger than the shank may destroy the drill canal and produce an unstable situation compared with screws with equal shank and thread diameter.

Holding power of the 4.5 mm AO/ASIF cortex screw in cortical bone in relation to bone mineral

To obtain basic data about the holding power of a 4.5 mm AO/ASIF cortex screw in cortical bone in relation to bone mineral as expressed by densitometric methods, uniaxial pull-out tests were performed on 14 human cadaver femurs. The mechanical parameters were correlated with bone mineral which was assessed by quantitative computed tomography (QCT) and dual energy X-ray absorptiometry (DXA). High correlations were found between the QCT mass, the DXA density and content values and the holding power of the screw. The QCT density values, expressing the physical density of the bone, did not correlate similarly well.

The clinical importance of DNA synthesis and aneuploidy in bone and soft tissue tumours

DNA flow cytometric analysis including the analysis of S-phase fraction was performed on 46 bone and soft tissue tumours. Histologically, 24 lesions were benign, 11 were low grade and 11 were high grade malignant tumours. The percentages of aneuploidy in these groups were 29, 54 and 82, respectively. The S-phase fraction was smaller than 14% in all benign tumours. High S-phase fraction (> or = 14%) was found in 3 out of 11 low-grade tumours (27%) and in 9 out 11 high-grade tumours (82%). Seven of nine patients who died of metastatic disease during the average 5 year follow-up had aneuploid stemlines with S-phase fraction higher than 14%. Histologically, these were all high-grade tumours. Three patients with high S-phase in low-grade tumours survived. We conclude that high DNA synthetic activity in an aneuploid population, more than the DNA aneuploidy alone, has prognostic significance in musculoskeletal tumours.

Prediction of fixation failure in femoral neck fractures. Comminution and avascularity studied in 40 patients

We performed 99m-Tc diphosphonate scintimetries in 40-elderly patients who had undergone screw fixation for a recent subcapital femoral fracture and analyzed their preoperative radiographs. The data were subjected to a logistic regression analysis. Both comminution of the calcar femorale and reduced scintimetric uptake were predictive for failure of the osteosynthesis during the first year. Fracture comminution was more predictive for early failures during 3 months and scintimetry for the later failures.