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.

Current concepts of respiratory insufficiency syndromes after fracture

Initial diligent resuscitation of the multiply-injured patient, with early fixation of the major orthopaedic injuries, has significantly reduced the incidence of post-traumatic respiratory complications from the unacceptably high levels which were seen 20 years ago. With these improvements we may be entering an era in which the risk of these complications is independent of the orthopaedic injury and is determined largely by the severity of injury to other body systems or by the immune and physiological status of the patient. Substantive proof of any beneficial effect from modification of the timing and technique of fracture stabilisation will be difficult to achieve without large multicentre randomised trials. It is conceivable that these interventions have a negligible effect on outcome or may actually be detrimental. Unravelling the basic molecular and cellular pathogenic processes of ARDS and FES will lead to improved therapeutic strategies for the treatment of this condition. For the present, however, the evidence suggests that expedient and appropriate early treatment of fractures in most instances protects against the development of post-traumatic respiratory insufficiency. Currently, the best and most effective therapeutic tool of the practising orthopaedic/trauma surgeon is prevention.

Decreased expression of TGF-beta cell surface receptors during progression of human oral squamous cell carcinoma

This study examined the immunocytochemical expression of the transforming growth factor-beta (TGF-beta) isoforms TGF-beta1, TGF-beta2, and TGF-beta3, together with the TGF-beta cell surface receptors TbetaR-I and TbetaR-II, in patient-matched tissue pairs of normal human oral epithelium, primary squamous cell carcinomas, and metastatic lymph node tumour deposits. There were no significant differences in the intensity of TGF-beta isoform specific staining between the normal oral epithelium, the primary tumours, and the lymph node metastases. By contrast, there was significantly less TbetaR-II in the metastases than in the primary tumour and between the primary tumour and the normal oral epithelium. Similar trends were evident with TbetaR-I, but not at a statistically significant level. This study also examined the structure of TbetaR-I and TbetaR-II in normal human oral keratinocytes in vitro and in 14 human oral carcinoma cell lines with known responses to TGF-beta1. No structural abnormalities of TbetaR-II were present in the normal keratinocytes or in 13 of 14 malignant cell lines; in one line, there were both normal and mutant forms of TbetaR-II, the latter being in the form of a frameshift mutation with the insertion of a single adenine base (bases 709-718, codons 125-128), predicting a truncated receptor having no kinase domain. No defects were present in TbetaR-I. The structures of TbetaR-I and TbetaR-II did not correlate with growth inhibition by TGF-beta1. The data suggest that decreased expression of TGF-beta receptors, rather than structural defects of these genes, may be important in oral epithelial tumour progression. In order to examine the functional significance of a specific decrease in TbetaR-II expression, a dominant-negative TbetaR-II construct (dnTbetaR-II) was transfected into a human oral carcinoma cell line with a normal TGF-beta receptor profile and known to be markedly inhibited by TGF-beta1. In those clones that overexpressed the dnTbetaR-II, growth inhibition and Smad binding activity were decreased, whilst the regulation of Fra-1 and collagenase-1 remained unchanged following treatment with TGF-beta1. The results demonstrate that a decrease in TbetaR-II relative to TbetaR-I leads to selective gene regulation with loss of growth inhibition but continued transcription of AP-1-dependent genes that are involved in the regulation of the extracellular matrix.

Decreased expression of TGF-beta cell surface receptors during progression of human oral squamous cell carcinoma

This study examined the immunocytochemical expression of the transforming growth factor-beta (TGF-beta) isoforms TGF-beta1, TGF-beta2, and TGF-beta3, together with the TGF-beta cell surface receptors TbetaR-I and TbetaR-II, in patient-matched tissue pairs of normal human oral epithelium, primary squamous cell carcinomas, and metastatic lymph node tumour deposits. There were no significant differences in the intensity of TGF-beta isoform specific staining between the normal oral epithelium, the primary tumours, and the lymph node metastases. By contrast, there was significantly less TbetaR-II in the metastases than in the primary tumour and between the primary tumour and the normal oral epithelium. Similar trends were evident with TbetaR-I, but not at a statistically significant level. This study also examined the structure of TbetaR-I and TbetaR-II in normal human oral keratinocytes in vitro and in 14 human oral carcinoma cell lines with known responses to TGF-beta1. No structural abnormalities of TbetaR-II were present in the normal keratinocytes or in 13 of 14 malignant cell lines; in one line, there were both normal and mutant forms of TbetaR-II, the latter being in the form of a frameshift mutation with the insertion of a single adenine base (bases 709-718, codons 125-128), predicting a truncated receptor having no kinase domain. No defects were present in TbetaR-I. The structures of TbetaR-I and TbetaR-II did not correlate with growth inhibition by TGF-beta1. The data suggest that decreased expression of TGF-beta receptors, rather than structural defects of these genes, may be important in oral epithelial tumour progression. In order to examine the functional significance of a specific decrease in TbetaR-II expression, a dominant-negative TbetaR-II construct (dnTbetaR-II) was transfected into a human oral carcinoma cell line with a normal TGF-beta receptor profile and known to be markedly inhibited by TGF-beta1. In those clones that overexpressed the dnTbetaR-II, growth inhibition and Smad binding activity were decreased, whilst the regulation of Fra-1 and collagenase-1 remained unchanged following treatment with TGF-beta1. The results demonstrate that a decrease in TbetaR-II relative to TbetaR-I leads to selective gene regulation with loss of growth inhibition but continued transcription of AP-1-dependent genes that are involved in the regulation of the extracellular matrix.

Overexpression of JunB in undifferentiated malignant rat oral keratinocytes enhances the malignant phenotype in vitro without altering cellular differentiation

Our study examined the expression of AP-1 family members in keratinocytes derived from the rat-4NQO model of oral carcinogenesis in which extremes of epithelial differentiation and tumour cell aggressiveness are evident. The constitutive expression of JunB was diminished in the undifferentiated, more aggressive tumour phenotype compared with the well-differentiated, less aggressive keratinocytes, whereas the expression of other AP-1 family members (c-jun, junD, c-fos, fra1, fra2 and fosB) was either very weak or variable. After transfection of the undifferentiated keratinocytes with junB cDNA, clonal populations were isolated that expressed similar levels of JunB protein as the well-differentiated cells. Both untransfected and transfected cell lines were keratin negative and vimentin positive. Increased expression of JunB in the transfected cells resulted in up-regulation of c-Jun and Fra1 and an enhanced AP-1 activity as demonstrated by transcriptional activation of the prototypic AP-1 dependent promoter, MMP-1. JunB transfected cells grew more quickly than vector-only controls and were refractory to the growth inhibitory effects of TGF-beta1. Over-expression of JunB resulted in the elevated expression of the AP-1 dependent proteinase, MMP-9, whereas the expression of the AP-1 independent enzyme, MMP-2, was unaffected. JunB transfected keratinocytes were highly invasive in an in vitro assay of tumour cell invasion compared with vector controls. The results indicate that increased expression of JunB above baseline levels in undifferentiated rat keratinocytes does not alter epithelial differentiation but enhances the malignant phenotype in vitro, possibly by altering the dynamics of the AP-1 complex.

Late fracture of the hip after reamed intramedullary nailing of the femur

In a consecutive series of 498 patients with 528 fractures of the femur treated by conventional interlocking intramedullary nailing, 14 fractures of the femoral neck (2.7%) occurred in 13 patients. The fracture of the hip was not apparent either before operation or on the immediate postoperative radiographs. It was diagnosed in the first two weeks after operation in three patients and after three months in the remainder. Age over 60 years at the time of the femoral fracture and female gender were significantly predictive of hip fracture on bivariate logistic regression analysis, but on multivariate analysis only the location of the original fracture in the proximal third of the femur (p = 0.0022, odds ratio = 6.96, 95% CI 2.01 to 24.14), low-energy transfer (p = 0.0264, odds ratio = 15.56, 95% CI 1.38 to 75.48) and the severity of osteopenia on radiographs (p = 0.0128, odds ratio = 7.55, 95% CI 1.54 to 37.07) were significant independent predictors of later fracture. Five of the 19 women aged over 60 years, who sustained an osteoporotic proximal diaphyseal fracture of the femur during a simple fall, subsequently developed a fracture of the neck. Eleven of the hip fractures were displaced and intracapsular and, in view of the advanced age of most of these patients, were usually treated by replacement arthroplasty. Reduction and internal fixation was used to treat the remaining three intertrochanteric fractures. Three patients developed complications requiring further surgery; five died within two years of their fracture.

Duration of immunity, efficacy and safety in sheep of a recombinant Taenia ovis vaccine formulated with saponin or selected adjuvants

The efficacy and safety of a recombinant Taenia ovis protein was tested in sheep using 13 different adjuvant formulations, including oil adjuvants, aluminium salts, saponin, Iscoms and DEAE-dextran. The oil adjuvants, saponin and DEAE-dextran gave the highest antibody responses and greatest degree of protection against challenge infection with T. ovis eggs. Duration of immunity studies with a saponin based vaccine showed that highly significant protection (>90% reduction of cyst numbers) was achieved when sheep were challenge infected one month after immunisation. Significant protection (79%) was still present when sheep were challenged 6 months after immunisation. The optimum dose for this batch of saponin was 10 mg, which stimulated a peak antibody titre of 38,400, 4 weeks after immunisation and did not cause injection site reactions. Dialysed saponin was shown to retain its adjuvant properties and allowed an increase in dose to 30 mg without site reaction, resulting in a peak antibody titre of 51,200.

Dropped hallux after the intramedullary nailing of tibial fractures

We made a prospective study of 208 patients with tibial fractures treated by reamed intramedullary nailing. Of these, 11 (5.3%) developed dysfunction of the peroneal nerve with no evidence of a compartment syndrome. The patients with this complication were significantly younger (mean age 25.6 years) and most had closed fractures of the forced-varus type with relatively minor soft-tissue damage. The fibula was intact in three, fractured in the distal or middle third in seven, with only one fracture in the proximal third. Eight of the 11 patients showed a 'dropped hallux' syndrome, with weakness of extensor hallucis longus and numbness in the first web space, but no clinical involvement of extensor digitorum longus or tibialis anterior. This was confirmed by nerve-conduction studies in three of the eight patients. There was good recovery of muscle function within three to four months in all cases, but after one year three patients still had some residual tightness of extensor hallucis longus, and two some numbness in the first web space. No patient required further treatment.

Support groups: an empowering, experiential strategy

The authors describe a student-facilitated support group experience initiated at student request and designed for RN-BSN students. Students report they emerged enlightened about group theory, empowered to share their knowledge of groups, and energized to initiate groups in their work settings. If educators make the learning experience safe, practice letting go and being vigilant, and celebrate group successes, students learn how to initiate, facilitate, and terminate small groups.

Fractures of the clavicle in the adult. Epidemiology and classification

From 1988 to 1994 a consecutive series of 1000 fractures of the adult clavicle was treated in the Orthopaedic Trauma Clinic of the Royal Infirmary of Edinburgh. In males, the annual incidence was highest under 20 years of age, decreasing in each subsequent cohort until the seventh decade. In females, the incidence was more constant, but relatively frequent in teenagers and the elderly. In young patients, fractures usually resulted from road-traffic accidents or sport and most were diaphyseal. Fractures in the outer fifth were produced by simple domestic falls and were more common in the elderly. A new classification was developed based on radiological review of the anatomical site and the extent of displacement, comminution and articular extension. There were satisfactory levels of inter- and intraobserver variation for reliability and reproducibility. Fractures of the medial fifth (type 1), undisplaced diaphyseal fractures (type 2A) and fractures of the outer fifth (type 3A) usually had a benign prognosis. The incidence of complications of union was higher in displaced diaphyseal (type 2B) and displaced outer-fifth (type 3B) fractures. In addition to displacement, the extent of comminution in type-2B fractures was a risk factor for delayed and nonunion.

Epidemiology of fractures in 15,000 adults: the influence of age and gender

We report a prospective study of the incidence of fractures in the adult population of Edinburgh, related to age and gender. Over a two-year period, 15,293 adults, 7428 males and 7865 females, sustained a fracture, and 5208 (34.0%) required admission. Between 15 and 49 years of age, males were 2.9 times more likely to sustain a fracture than females (95% CI 2.7 to 3.1). Over the age of 60 years, females were 2.3 times more likely to sustain a fracture than males (95% CI 2.1 to 2.4). There were three main peaks of fracture distribution: the first was in young adult males, the second was in elderly patients of both genders, mainly in metaphyseal bone such as the proximal femur, although diaphyseal fractures also showed an increase in incidence. The third increase in the incidence of fractures, especially of the wrist, was seen to start at 40 years of age in women. Our study has also shown that 'osteoporotic' fractures became evident in women earlier than expected, and that they were not entirely a postmenopausal phenomenon.

Results of an operative policy in the treatment of periprosthetic femoral fracture

OBJECTIVE

To determine the clinical outcome of patients with periprosthetic femoral fractures treated operatively.

DESIGN

Retrospective analysis from 1986 to 1993.

SETTING

Edinburgh Orthopaedic Trauma Unit, Edinburgh, Scotland.

PATIENTS

Forty-five patients identified from a computer database as being admitted to the Edinburgh Orthopaedic Trauma Unit with periprosthetic femoral fractures.

MAIN OUTCOME MEASURES

Clinical outcome grade (good, fair, poor) dependent on integrity of fixation, refracture rate, and ability to perform activities of daily living analyzed against age, type of fracture, prosthetic alignment, loosening, and method of fixation.

RESULTS

Type I fractures were more common in uncemented or loosely cemented prostheses, whereas type II fractures occurred predominantly in securely cemented prostheses. Type I fractures treated by revision had the poorest results. Outcome in type II fractures was equally good whether treated by internal fixation or by revision. Age, loosening, and prosthetic alignment did not influence outcome. The mortality rate in this series was 20%.

CONCLUSIONS

If a prosthesis is loose, it should be revised, or treatment varies with fracture and prosthetic type. In type I fractures, an uncemented stem may be revised to a cemented one; however, a securely cemented prosthesis probably is better when fixed internally. Type II fractures should be fixed internally because there is less operative insult. Type III fractures probably are not related to the prosthesis and should be fixed internally according to normal practice. The results of an operative policy compare well with the results of conservative management and avoid the problems of long-term immobilization.

Detection of donor-specific hyporesponsiveness following late failure of human renal allografts

Limiting dilution assays to measure the frequency of interleukin-2-secreting peripheral blood T cells were carried out in patients, whose renal allografts had failed due to acute rejection (9 patients) and in patients whose grafts failed more than two years after transplantation without any recent evidence of acute rejection. Using a modified form of the assay we demonstrate that nearly half of 18 patients whose renal transplants had failed after more than two years have low or undetectable HTLp frequencies against donor, but not third-party DR antigens. No such difference was observed in any of the nine patients studied whose transplants were lost from early acute rejection. These results provide the first indication that, as in rodent models of transplantation, T cell unresponsiveness towards donor MHC antigens can occur following prolonged residence of an allograft in humans. Furthermore, the results suggest that chronic rejection may be driven by mechanisms other than direct allorecognition. The assay may be a valuable tool to study the evolution of donor-specific direct T cell alloresponsiveness in patients with well-functioning grafts.

Pilot field trial of a recombinantTaenia ovisvaccine in lambs exposed to natural infection

Previous trials of an experimental Taenia ovis vaccine using the recombinant antigen GST--45W(B/X) established that it was possible to achieve >90% protection against a single artificial challenge of T. ovis eggs. This trial was undertaken to assess vaccine efficacy against artificial challenge and natural infection acquired by lambs grazing contaminated pasture. Two hundred Romney lambs were vaccinated at 6 and 12 weeks of age. One hundred control lambs were not vaccinated but were allowed to run with the vaccinated mob. At 15 weeks of age, 10 controls and 18 vaccinated lambs were artificially challenged with 2000 T. ovis eggs. The remaining control and vaccinated lambs were allowed to graze contaminated pasture for 3 weeks and were then moved to clean pasture for 5 months. The artificially challenged lambs plus 24 of the field-infected lambs were slaughtered and the carcasses dissected to obtain cyst counts. The remaining field-infected lambs were slaughtered at a commercial processing plant and the carcasses examined by conventional meat inspection. The results showed that the vaccine provided a high level of protection against artificial challenge (92%) and natural infection (98%) when assessed by carcass dissection. The data from commercial meat inspection showed that vaccination provided 89% efficacy against downgrading or condemnation compared to non-vaccinated control lambs. The average difference in carcass values between vaccinated and non-vaccinated groups was 4.36 dollars, representing a 35% loss in value due to T.ovis infection in non-vaccinated lambs.

Juvenile idiopathic scoliosis. Curve patterns and prognosis in one hundred and nine patients

We reviewed the medical records and radiographs of 109 consecutive patients who had juvenile idiopathic scoliosis. The sixty-seven girls and forty-two boys were a mean of six years and ten months old (range, three years and four months to nine years and eleven months old) when the curve was recognized. One hundred and four patients had a progressive curve: twenty-eight had a single mid-thoracic curve with the apex usually at the eighth thoracic vertebra (Group 1A), twenty-nine had a major mid-thoracic curve with the apex usually at the eighth thoracic vertebra and a secondary minor lumbar curve (Group 1B), twenty-seven had a single thoracic curve with the apex usually at the ninth or tenth thoracic level (Group 2), eight had a single thoracolumbar curve with the apex at the twelfth thoracic level (Group 3), and twelve had a major lumbar curve with the apex at the second or third lumbar level and a secondary minor thoracic curve (Group 4). Five patients (5 per cent) had a resolving curve. Eighty-nine of the patients who had a progressive curve were followed to skeletal maturity. Eighty-eight patients were managed with a brace. The curve progressed at a rate of 1 to 3 degrees per year before the age of ten years and 4.5 to 11 degrees per year after the age of ten years. In sixty-seven of the eighty-four patients in Groups 1 and 2, a spinal arthrodesis was performed before the age of fifteen years (mean age, eleven years and ten months; range, nine years and three months to fourteen years and eight months), at which time the mean curve was 47 degrees (range, 24 to 90 degrees). Eight patients were not seen by us until they were fifteen years old or more, at which time the thoracic curve was 74 to 120 degrees; a spinal arthrodesis was done in seven. The curves in Groups 3 and 4 had a more benign prognosis, and only three patients in these two groups had an arthrodesis. The pattern of the final curve was not always apparent at an early stage, and there was extension of the primary curve or development of secondary structural curves with progression. The chief prognostic feature at an early stage was the level of the most rotated vertebra at the apex of the primary curve, and the final pattern of deformity was defined by the level of the caudad neutral vertebra in the primary thoracic curve.

Parasite vaccine development: large-scale recovery of immunogenic Taenia ovis fusion protein GST-45W(B/X) from Escherichia coli inclusion bodies

Genetically modified Escherichia coli expressing the Taenia ovis fusion protein GST-45W(B/X) as inclusion bodies were grown in volumes ranging up to 1000 l. Bacteria were inactivated by heat or chemical treatment without affecting immunogenicity. The fusion protein was recovered in a highly immunogenic form from washed inclusion bodies and from urea-solubilised inclusion bodies. The fusion protein was found to be stable in solution after storage at 4 degrees C for up to 2 years. Vaccines formulated with fusion protein from urea-soluble inclusion bodies gave consistently high protection (89-100%) against challenge infection. The methods described enabled the production of sufficient vaccine for large field trials. These trials generated the data required for product registration and manufacture of a vaccine to prevent T. ovis infection in sheep.

Fracture of the metal tibial tray after Kinematic total knee replacement. A common cause of early aseptic failure

We reviewed 1567 elective knee replacements performed between 1980 and 1990, using either the Total Condylar prosthesis with an all-plastic tibial component, or the Kinematic prosthesis which has a metal tibial tray. The ten-year probability of survival was 92.1% for the Total Condylar design and 87.9% for the Kinematic. The difference was mainly due to 16 revisions required in the Kinematic series for fracture of the metal base-plate. This was the most common cause of aseptic failure in this group. These fractures were strongly associated with a preoperative varus deformity (hazard ratio (HR) 8.8) and there was a slightly increased risk in males (HR 1.9) and in osteoarthritic knees (HR 1.8). In the nine fractures which occurred within four years of primary implantation (group 1), failure to correct adequately a preoperative varus deformity and the use of a bone graft to correct such a deformity were both strongly associated with fracture (HR 13.9 and 15.8, respectively). In eight fractures which occurred more than five years after primary replacement (group 2) we could detect no significant risk factors. Early complications occurred in two patients after the 16 revision procedures for tray fracture. One had a deep infection and the other refracture of the tray.

Identification and cDNA cloning of two novel low molecular weight host-protective antigens from Taenia ovis oncospheres

Oncosphere antigens of Taenia ovis were solubilised in sodium dodecyl sulphate and separated by electrophoresis in polyacrylamide gels (SDS-PAGE). Antigen-containing gel fractions cut from the region covering 18-12 kDa were shown to be highly immunogenic in sheep challenge experiments. Specific antisera against 2 candidate antigens at 18 and 16 kDa were used to screen a cDNA library prepared from T. ovis oncosphere mRNA. Recombinant proteins selected with antibody to the 16 and 18 kDa native antigens were expressed as GST fusion proteins. Vaccination trials using either of the 2 fusion proteins To16.17-GST and To18-GST, revealed that each was capable of inducing high levels of immunity in sheep against challenge infection with T. ovis eggs. Antibodies induced by vaccination with the recombinant antigens reacted specifically with their respective 18 or 16 kDa native oncosphere antigens. There was no apparent homology between the T. ovis cDNA coding for To18 and To16.17, or with another host-protective antigen, To45W, described previously. These additional host-protective antigens should prove a valuable adjunct to To45W and permit the development of effective vaccination strategies.

Oral psoriasis

We present a patient with oral lesions consistent with a diagnosis of oral psoriasis and discuss the relationship of oral and skin lesions in psoriasis.

Tibial fractures with bone loss treated by primary reamed intramedullary nailing

We reviewed the results of the treatment of 30 tibial fractures with minor to severe bone loss in 29 patients by early soft-tissue and bony debridement followed by primary locked intramedullary nailing. Subsequent definitive closure was obtained within the first 48 hours usually with a soft-tissue flap, and followed by bone-grafting procedures which were delayed for six to eight weeks after the primary surgery. The time to fracture union and the eventual functional outcome were related to the severity and extent of bone loss. Twenty-nine fractures were soundly united at a mean of 53.4 weeks, with delayed amputation in only one patient. Poor functional outcome and the occurrence of complications were usually due to a departure from the standard protocol for primary management. We conclude that the protocol produces satisfactory results in the management of these difficult fractures, and that intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilisation.

Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing

We reviewed 63 patients with fractures of the distal tibial metaphysis, with or without minimally displaced extension into the ankle joint. The fractures had been caused by two distinct mechanisms, either a direct bending force or a twisting injury. This influenced the pattern of the fracture and its time to union. All fractures were managed by statically locked intramedullary nailing, with some modifications of the procedure used for diaphyseal fractures. There were few intra-operative complications. At a mean of 46 months, all but five patients had a satisfactory functional outcome. The poor outcomes were associated with either technical error or the presence of other injuries. We conclude that closed intramedullary nailing is a safe and effective method of managing these fractures.

Transcardiac echocardiography during invasive intramedullary procedures

We performed transoesophageal echocardiography in 111 operations (110 patients) which included medullary reaming for fresh fractures of the femur and tibia, pathological lesions of the femur, and hemiarthroplasty of the hip. Embolic events of varying intensity were seen in 97 procedures and measured pulmonary responses correlated with the severity of embolic phenomena. Twenty-four out of the 25 severe embolic responses occurred while reaming pathological lesions or during cemented hemiarthroplasty of the hip and, overall, pathological lesions produced the most severe responses. Paradoxical embolisation occurred in four patients, all with pathological lesions of the femur (21%); two died. In 12 patients large coagulative masses became trapped in the heart. Extensive pulmonary thromboembolism with reamed bone and immature clot was found at post-mortem in two patients; there was severe systemic embolisation of fat and marrow in one who had a patent foramen ovale and widespread mild systemic fat embolisation in the other without associated foraminal defect. Sequential analysis of blood from the right atrium in five patients showed considerable activation of clotting cascades during reaming.

Transcardiac echocardiography during invasive intramedullary procedures

We performed transoesophageal echocardiography in 111 operations (110 patients) which included medullary reaming for fresh fractures of the femur and tibia, pathological lesions of the femur, and hemiarthroplasty of the hip. Embolic events of varying intensity were seen in 97 procedures and measured pulmonary responses correlated with the severity of embolic phenomena. Twenty-four out of the 25 severe embolic responses occurred while reaming pathological lesions or during cemented hemiarthroplasty of the hip and, overall, pathological lesions produced the most severe responses. Paradoxical embolisation occurred in four patients, all with pathological lesions of the femur (21%); two died. In 12 patients large coagulative masses became trapped in the heart. Extensive pulmonary thromboembolism with reamed bone and immature clot was found at post-mortem in two patients; there was severe systemic embolisation of fat and marrow in one who had a patent foramen ovale and widespread mild systemic fat embolisation in the other without associated foraminal defect. Sequential analysis of blood from the right atrium in five patients showed considerable activation of clotting cascades during reaming.

Medullary lavage reduces embolic phenomena and cardiopulmonary changes during cemented hemiarthroplasty

We randomised 24 patients before they had a cemented hemiarthroplasty for hip fracture to receive either thorough or minimal saline lavage of the femoral canal. We then determined the effect in each group on the thromboembolic and cardiopulmonary responses to the pressurised insertion of cement, using transoesophageal echocardiography to show the echogenic embolic response. We found a statistically significant reduction in both the duration of the response and the number of large emboli in patients who had had thorough lavage as compared with the control group with minimal lavage. There was also less disturbance of pulmonary function, as assessed by the change in end-tidal CO2 levels and oxygen saturation, in patients who had thorough lavage. Three patients had a significant fall in blood pressure during cement insertion; all had only minimal lavage. We consider that thorough lavage should be an essential part of the preparation of the proximal femur before cement insertion.

Hip fractures in adults younger than 50 years of age. Epidemiology and results

A review of the records of 3147 patients with hip fractures admitted to the authors' institution during a 5-year period revealed that 95 (3%) patients were aged 50 years or less at the time of fracture. Of patients between the ages of 20 and 40 years, hip fracture most commonly occurred in men after high-energy injuries. These injuries commonly occurred in the subtrochanteric and basicervical regions, or as a vertical transcervical fracture. In contrast, most patients between 40 and 50 years of age were medically frail and sustained osteoporotic-type fractures during simple falls. A treatment protocol of early reduction followed by internal fixation was evaluated in 75 nonpathologic fractures. At a mean of 25 months, fracture union with a good or satisfactory functional outcome was found in 57 (76%) patients, and 5 (7%) patients died of unrelated medical problems. Complications of primary treatment developed in 16 (21%) patients, but only 13 (17%) revision procedures were required. A satisfactory functional outcome was found in 10 patients who had uncomplicated revision surgery, but there were poor functional results in the 3 who required tertiary surgery. Despite the previously reported poor results of treatment of hip fracture in young adults, these results demonstrate that satisfactory results can be achieved with early, accurate fracture reduction followed by rigid internal fixation.

Nonsteroidal antiinflammatory drugs, perioperative blood loss, and transfusion requirements in elective hip arthroplasty

A study of 160 elective total hip arthroplasties revealed that those patients receiving nonsteroidal antiinflammatory drugs (NSAIDs) in the preoperative period had a significantly increased perioperative blood loss and transfusion requirement when compared with a control group receiving other forms of analgesia for their osteoarthritis. The results suggest that NSAIDs are implicated in increasing the operative blood loss in these patients. The range of increased blood loss varied from 1.57 to 2.08 times the blood loss in the control group, and this effect was seen when the operation was carried out under spinal as well as when under general anesthesia.

The two-part proximal humeral fracture: a review of operative treatment using two techniques

A review of 45 patients who have undergone surgery for two-part fractures of the proximal humerus (Neer Group III) is reported using two operative techniques, AO plating and intramedullary Rush pins. Good functional results were obtained using the former technique in seven out of eight of the patients under the age of 50 years who mainly sustained their original injury as a result of high-energy motor vehicle accidents. However, in the more common low-energy, osteoporotic fracture in the elderly population, results were unsatisfactory in 12 out of 14 cases where AO plating was used, usually as a result of fixation failure. The Rush pin technique produced more reliable results in this age group, with satisfactory functional scores being obtained in 16 out of 23 patients. It is suggested that the Rush pin technique is preferable to plate fixation in the more common osteoporotic insufficiency fracture in the elderly.

Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period

We report the results of locked Seidel nailing for 30 fractures of the humerus. There were frequent technical difficulties at operation especially with the locking mechanisms. Protrusion of the nail above the greater tuberosity occurred in 12 cases, usually due to inadequate locking, and resulted in shoulder pain and poor function. Poor shoulder function was also seen in five patients with no nail protrusion, presumably because of local rotator cuff damage during insertion. Our results suggest that considerable modifications are required to the nail, and possibly to its site of insertion, before its use can be advocated.

Changing prevalence of osteomalacia in hip fractures in southeast Scotland over a 20-year period

In a randomized study of 81 patients with fresh hip fractures who underwent bone biopsy at the time of surgery there was no histologically detectable osteomalacia. This represented a fall in prevalence since a similar study 20 years previously had shown a 12 per cent incidence in the same population. The implications for routine histological screening and measurement of serum bone biochemistry in patients with hip fractures is discussed. The majority of patients in the study group had histologically detectable osteoporosis suggesting that this was an important factor in the aetiology of femoral neck fractures.

Passive immunotherapy for mouse leukemias with antisera of "directed" specificity: synergism with the action of cyclophosphamide

Antileukemia sera with "directed" specificity are produced by immunization of rabbits with mouse leukemia cells admixed with normal antigen blocking (NAB) serum. Addition of NAB serum to the leukemia cells inhibits production of antibodies to normal cell components and directs specificity toward leukemia cell antigens. The resulting antileukemia serum (ALK-NABS) was not sufficiently potent to produce more than moderate therapy in the standard L1210 leukemia therapy assay. When given together with noncurative doses of cyclophosphamide (CTX), ALK-NABS acts synergistically. It is most effective when given early after injection of the leukemia cells and prior to injection of CTX. Daily repeated injections of a given dose are more effective than a single injection of that dose. Most important, small doses of ALK-NABS produce a significant prolongation of lifespan in conjunction with CTX. Results of therapy for BW-A leukemia with ALK-NABS in conjunction with CTX were negative.

Assay of immune cytolysis of lymphocytes and tumour cells by automatic determination of cell volume distribution

Immune cytolysis (lysis) of cells due to the action of antibody in the presence of complement is usually substantiated by the uptake of vital dye by the cells, or by the escape of radiolabel from the cells. Immune cytolysis has now been assayed by determination of cell volume distribution with a Coulter multi-channel particle size analyser used in conjunction with a Coulter counter. For Ehrlich ascites and sarcoma-180 cells, volume degradation corresponding to vital staining was obtained only if trypsin (final concentration 625 microgram/ml) was added immediately after the usual 1 h incubation period for cells, antibody and complement. For L1210 leukaemia cells, trypsin was added at 0 degrees just 1 min before Coulter evaluation, to avoid potentiation of antibody-mediated cell lysis by trypsin. Immune cytolysis of mouse thymic, splenic and lymph node lymphocytes required addition of pronase (final concentration 625 microgram/ml) at 0 degrees for further disruption of antibody-damaged cells, prior to determination of cell volume distribution in the Coulter equipment. Scanning electron micrographs of L1210 cells undergoing immune cytolysis illustrated the changes in cell volume recorded by the Coulter apparatus. This new method for determination of immune cytolysis provides detailed information about the volume distribution of target cells, which permits detection of subtle changes and gives insight into the process of cytolysis. It is not intended to displace other procedures in routine use, except that complete automation of the present method is possible in future.

Preparation and therapeutic potential of rabbit antisera with "directed" specificities for mouse leukemias

Several immunization regimens for preparation of ALK-NABS were compared. One series of eight intravenous injections spaced over 5 weeks gave an ALK-NABS with potency and specificity that could be bettered only slightly by a second series of four injections spaced over 2 weeks, whereas a third series of injections was deleterious. Use of late immune antisplenocyte NABS for such immunizations produced ALK-NABS reagents with the highest in vitro specificity to leukemia cells relative to splenocytes after absorption, whereas early immune antisplenocyte NABS gave ALK-NABS with the highest antileukemia specificity relative to thymocytes. Therapy experiments with leukemias L1210 and BW-A showed increased survival times for isogeneic mice injected intraperitoneally with 10(3) (L1210 only), 10(4), and 10(5) (higher significance for L1210) cells, when ALK-NABS was given intraperitoneally in high dose on 4 or 5 successive days starting 1 day after inoculation of leukemia cells. In additional experiments with 10(5) cells given intraperitoneally, lower doses of ALK-NABS were progressively more effective with L1210 leukemia, producing some survivors without any apparent toxicity from the antiserum. In contrast, a similar experiment with leukemia BW-A was entirely negative. Addition of guinea pig serum to already excessive amounts of antiserum was not helpful.

Enzymatic degradation of tumor cells damaged by antibody plus complement

Rapid degradation of ascites tumor cells damaged by the action of antibody plus complement was found to be accomplished by all proteolytic enzymes active at physiologic pH that were tested. For three types of murine ascites tumor cells (Ehrlich ascites, sarcoma-180, and L1210 leukemia), this rate of degradation at low trypsin concentrations was proportional to a high power of enzyme concentration. This suggests that the simultaneous action of two or more enzyme molecules at adjacent cell surface sites is necessary. Cell degradation was assayed by determination of cell volume distribution with a Coulter multi-channel particle size analyzer. The present study may offer clues to in vivo mechanisms of cell degradation.

Transurethral prostatectomy in patients with severe hip deformity

The use of a modified lithotomy position and perineal urethrotomy has permitted transurethral prostatectomy in patients with severe hip disease. The procedure is described.

'Sufficient' absorption--a quantitative method to replace 'exhaustive' absorption

At present, the only guideline for removal of undesired reactivities from an antiserum is that no activity against the cross-reacting (undesired) antigens should remain after exhaustive absorption. Since this guideline sets no upper limit on the amount of undesired antigens required for an exhaustive absorption, waste of possibly precious material and of time in performing multiple sequential absorptions can result. To minimize the quantity of antigen and of experimental work required for an absorption, a quantitative approach is suggested: the antiserum is test-absorbed with various amounts of the undesired antigens, and antibody activity still present against these antigens is then tested. The results can be plotted as a curve by use of Reif's modification of the Von Krogh equation. Thus, the exact amount of undersired antigens sufficient to remove all detectable reactivity against these antigens can be determined. The procedure is termed 'sufficient' rather than 'exhaustive' absorption, to stress that only detectable amounts (rather than every last trace) of undesirable antibodies have been removed. The nomenclat re 'exhaustive absorption' gives no indication that any practical attempt to achieve it can hardly escape having the same limitations as 'sufficient absorption'; it is therefore suggested that the misleading non-quantitative nomenclature 'exhaustive absorption' be eliminated from immunological terminology. 'Sufficient absorption' has been applied to the absorption of undesired (blood group) antibodies from rabbit antisera to CEA.

Proportional absorption. A method for determination of the relative specificity of antisera prepared against cells

Antisera prepared against a complex of antigens such as a tissue cell may produce a mixture of antibodies of different specificities, affinities and types. Proportional absorption permits determination of the comparative specificity of such antisera. It is performed by absorbing the antisera with an amount of absorbent proportional to the initial content of (usually undesired) antibody to this absorbent; the potencies of desired and undesired antibodies are then separately determined. The method has been used to determine the specificity of a conventionally raised rabbit anti-mouse leukaemia serum, relative to one prepared with leukaemia cells admixed with rabbit antiserum against normal mouse lymphocytes (to block normal antigen sites on the leukaemia cell inoculum). The latter antiserum was cells as compared to normal splenic lymphocytes.