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PubMed1994

Social aspects in patients following proximal femoral fractures.

Between January 1989 and December 1990, a study was conducted on the social aspects of 123 patients admitted to the Singapore General Hospital, Department of Orthopaedic O, with proximal femoral fractures. Twenty-three patients passed away, leaving 100 patients for review at 2 years post-fracture. Of the 20 social functions evaluated, less than 60% improvement was observed in 6 lower limb dependent activities. Before fracture, 82 patients were independent and 83 were ambulating without aids. After fracture, improvement occurred progressively and reached a plateau at 1 year with 62 (75.6%) patients independent and 41 (49.4%) patients ambulating normally. All the patients stayed in their own home before fracture and 90 (90%) patients returned to their home after their discharge. Of the 59 patients who were unable to ambulate without aids, 21 had visual problems, 9 had cerebrovascular accident and 8 had both problems.

Accidental Falls↗
PubMed2000

Expression of bone morphogenetic proteins and rat distal-less homolog genes following rat femoral fracture.

Expression of the genes encoding bone morphogenetic proteins (BMPs), BMP type IA receptor (BMPR-1A), and rat distal-less homolog (rDlx) was studied in bone, callus, and the surrounding soft tissue following rat femoral closed fracture, using RT-PCR-based techniques. Before fracture, the genes encoding BMP-5, BMP-6, and BMPR-1A were found to be expressed in both bone and the surrounding soft tissue, whereas the BMP-2 gene was expressed only in bone and BMP-7 was not expressed in either tissue. Expression of these genes was unaffected by fracture. The gene encoding BMP-4 was also expressed in both bone and the surrounding soft tissue before fracture. Moreover, although unchanged in bone, 6 h after fracture BMP-4 expression was increased tenfold in the surrounding soft tissue. The increased BMP-4 expression was transient and returned to prefracture levels within 72 h. Expression of rDlx was also increased in bone after fracture, but at later times than were observed with BMP-4: elevated rDlx expression was detected after 48 h and persisted for 30 days or more. No expression of rDlx was observed in the surrounding soft tissue before or after fracture. These findings indicate that BMP-4 and rDlx are selectively expressed following femoral fracture in the rat, and also suggest that they are involved in the formation of the callus at an early point during the postfracture healing of bone.

Alkaline Phosphatase↗
PubMed2006

An analysis of the feasibility of home rehabilitation among elderly people with proximal femoral fractures.

OBJECTIVE: To evaluate the feasibility and predictors of success of home-based rehabilitation (HBR) in older adults after hip fracture. DESIGN: Prospective inception cohort study with 12 months of follow-up. SETTING: Acute and subacute care with follow-up in a community setting in Italy. PARTICIPANTS: Community-dwelling older adults (N=199) aged 70 years or older, discharged from an acute orthopedic unit after repair of a nontraumatic proximal femoral fracture. INTERVENTIONS: Patients' choice of pursuing HBR or institutional-based rehabilitation (IBR). MAIN OUTCOME MEASURES: Proportion of subjects discharged home for rehabilitation. Rates of institutionalization assessed at 3, 6, and 12 months postdischarge. Mean changes of the Barthel Index from baseline and proportion of subjects who regained their prefracture levels of function at the time of follow-up in the 2 intervention groups (HBR, IBR). RESULTS: Ninety-nine (49.7%) patients chose HBR, and the rest (50.3%) were discharged to a rehabilitation facility. With regard to the baseline characteristics, the 2 patient groups (HBR, IBR) differed with respect to living arrangement (P< or =.001), prefracture functional status in basic (Barthel Index, P=.033; Katz Index, P=.041) and instrumental activities of daily living (IADLs) (P=.041), and occurrence of delirium (P=.022). During the follow-up, the number of subjects institutionalized at 3, 6, and 12 months was 52, 26, and 22, respectively. In the multiple logistic regression model, the only significant variable affecting the choice of IBR at discharge was the absence of relatives at home (odds ratio [OR], 6.7; 95% confidence interval [CI], 3.33-13.46; P< or =.001), whereas a prefracture functional impairment in more than 3 IADLs (at 12 mo: OR=3.99; 95% CI, 1.57-10.18; P=.004), the absence of relatives at home (at 12 mo: OR=8.81; 95% CI, 2.47-31.46; P=.001), and delay to surgery longer than 3 days (at 12 mo: OR=5.51; 95% CI, 1.28-23.81; P=.022) resulted in significant risk factors for long-term institutionalization. Compared with subjects who received traditional rehabilitation, those discharged home showed--after controlling for prefracture Barthel Index score, IADLs, cognitive status and age--a slightly lower functional decline and a higher rate of recovery during the follow-up (mean change in Barthel Index score +/- standard deviation at 12 mo: HBR, -11.2+/-24.7 vs IBR, -23.7+/-28.5; P=.015). CONCLUSIONS: In an unselected population of hip-fractured older adults previously living in the community, HBR seems to be a feasible alternative to IBR in those subjects living with relatives.

Activities of Daily Living↗
PubMed2006

Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults.

BACKGROUND: Displaced intracapsular fractures may be treated by either reduction and internal fixation, which preserves the femoral head, or by replacement of the femoral head with an arthroplasty. OBJECTIVES: To review all randomised controlled trials that have compared internal fixation with arthroplasty for intracapsular femoral fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 4), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles. We contacted trialists where possible. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adults. DATA COLLECTION AND ANALYSIS: Trial quality was assessed by use of a 10 item scale. At least two review authors independently assessed trial quality and extracted data. Additional information was sought from trialists. After grouping into three broad categories, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed-effect model. MAIN RESULTS: Seventeen trials involving 2694 participants were included. Length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection were significantly less for internal fixation compared with arthroplasty. Arthroplasty had a significantly lower re-operation rate in comparison with fixation. No definite differences for hospital stay, mortality, or regain of same residential state were found. Limited information from some studies suggested pain was less and function was better for a cemented arthroplasty in comparison to fixation. AUTHORS' CONCLUSIONS: Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip. Definite conclusions cannot be made for differences in pain and residual disability between the two groups. Future studies should concentrate on better reporting of final outcome measures and there is still a need for studies to define which patient groups are better served by the different treatment methods.

Adult↗
PubMed2000

Relationships between femoral fracture loads for two load configurations.

Studies of proximal femoral strength usually involve one of two types of loading conditions, loading similar to joint loading during single-limb stance or loading simulating impact from a fall. When interpreting the results of studies involving only one of these load configurations, the question arises as to their applicability to the other configuration. In addition, it is desirable to know whether, for an individual bone, fracture load for one load configuration is indicative of fracture load for the other configuration. In this study, the relationship between proximal femoral fracture loads for single-limb stance loading and loading simulating impact from a type of fall was determined from mechanical testing of 17 matched pairs of human proximal femora. Fracture loads for these two configurations were found to be linearly related (r = 0.901, p < 0.001). However, the correlation between fracture loads is not notably stronger than correlations currently available between fracture load and measures of bone density and geometry. In addition, the regression results indicate that 81% of the variance in fracture load for one loading condition is accounted for by fracture load for the other loading condition. Thus, 19% of the variance remains unexplained, indicating that the results of studies involving only one load configuration are not necessarily indicative of those that would be found for another configuration.

Accidental Falls↗
PubMed1997

Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures.

In a prospective study, 14 cases of supracondylar or subtrochanteric fractures or osteotomies were stabilized with a dynamic condylar screw (DCS) inserted using a minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. The technique consisted of 4 major steps: 1) placement of the guide wire under fluoroscopic control and condylar screw insertion through a stab incision; 2) plate insertion beneath the vastus lateral muscle; 3) engagement of the condylar screw to the plate using a modified T-handle and, 4) plate fixation to the shaft using percutaneously inserted self-cutting screws. Between October 1994 and December 1995, 14 cases in 12 patients met the inclusion criteria. There were 11 acute fractures (6 subtrochanteric, 5 supracondylar) and 3 corrective osteotomies. Nine fractures were closed, and 2 were open. One 97-year-old patient died 6 weeks after trauma. There were no infections and 12 of 13 cases healed without a second procedure. There was 1 implant failure (plate screw breakage), which required repeat fracture fixation. At follow-up, there were 2 varus deformities above 5 degrees, 2 shortenings over 20 mm, and 1 rotational deformity of 20 degrees. According to the Neer score, there were 6 excellent, 1 satisfactory, 3 unsatisfactory results and no failures. The results of this technique compare favourably with those of other series of osteosynthesis of subtrochanteric or supracondylar femoral fractures treated with internal fixation without the added morbidity associated with an extensive approach or autogenous bone grafting. However, the surgical technique is demanding, and care must be taken to restore the axial alignment.

Adult↗
PubMed1990

Antibiotic prophylaxis in proximal femoral fracture.

A prospective randomized double-blind trial was carried out to assess the effectiveness of one dose of prophylactic cefuroxime versus placebo in 502 patients who underwent surgery for a proximal femoral fracture. With an overall deep infection rate of 2.2 per cent there was no significant difference in the superficial or deep wound infection rate between the two groups. However, there was a significant reduction in the incidence of postoperative bacteriuria in the cefuroxime group. A study of three doses of cefuroxime versus placebo is now proposed.

Adult↗
PubMed2002

Effects of intramedullary femoral fracture fixation: what is the impact of experimental studies in regards to the clinical knowledge?

This review manuscript summarizes the available literature on animal studies dealing with the local and systemic effects of intramedullary (IM) reamed and unreamed nailing. It focuses on the question of whether the large numbers of studies have contributed to our clinical knowledge about its impact on perfusion, fracture healing, and about the clinical relevance of systemic side effects. The effects of IM contents that are squeezed out of the medullary canal into the venous and the systemic circulation due to reaming and nailing has been a major issue. In addition, the impact of the surgical procedure and the timing of such a major operation as femoral fractures surgery has been a major source of debate within the last decade. The compilation of relevant studies investigating the degree of impact of a surgical procedure and the influence of concomitant injuries depends on the design and the type of the animal model. If this fact is considered and if a model is selected that reflects the systemic impact comparable with the clinical situation, animal studies represent a valuable source of information. In this respect, fat embolization represents an additive surgical impact and can cause clinically relevant side effects if cofactors (e.g., thoracic trauma, severe shock, and polytrauma) are present that set the individual up for postoperative complications.

Animals↗
PubMed1998

Pathologic femoral fracture after periosteal excision and radiation for the treatment of soft tissue sarcoma.

BACKGROUND: Surgical resection and adjuvant radiation therapy are standard therapy for soft tissue sarcomas. When the tumor approximates bone, periosteal excision may be necessary. It was hypothesized that periosteal stripping and radiation therapy would increase the rate of pathologic fracture. METHODS: The soft tissue sarcoma data base at the Memorial Sloan-Kettering Cancer Center was used to identify a consecutive series of 205 patients who were treated over a 15-year period (1982-1997). All patients had a soft tissue sarcoma of the thigh, which was managed by limb-sparing surgery and radiation therapy. Patients who had bone invasion by tumor or bone resection were not included. RESULTS: Nine patients, including eight women and one man, developed a femoral fracture in an area of previous radiation and surgery. All nine patients had undergone periosteal excision. The risk of fracture, by Kaplan-Meier survivorship, was 29% at 5 years if the resection included periosteum (P < 0.0001). Cox multiple regression analysis showed that periosteal excision was the only independent prognostic factor for the entire set of 205 patients at risk. However, for the subset of 54 patients who had periosteal stripping, two factors were also found to be prognostically important: female gender (P=0.022) and chemotherapy (P=0.020). The risk of fracture was 47% and 45%, respectively. The treatment of the fractures was difficult. There were four nonunions and three delayed unions. CONCLUSIONS: Periosteal stripping and radiation therapy places the femur at high risk of pathologic fractures, especially for female patients and patients undergoing chemotherapy. When practical, the combination of periosteal stripping and radiation should be avoided.

Adult↗