Mortality after Hip Fractures

A survey was made of 1592 patients, over the age of 50 years, who had sustained a fracture of the hip.

The mean age was found to be 77 years, and 76.9 per cent (1224/1592) of the patients were women. Trochanteric fractures accounted for 52.5 per cent (836/1592) of the cases and these patients had a higher mean age than those with femoral neck fractures.

The average hospitalization time was 24 days and the mortality during the hospital stay was 8.6 per cent (137/1592). Statistical analysis revealed that the hospital mortality rate was related exclusively to the age and the sex.

The mortality after 3 months was 17 per cent and that after 6 months 21.5 per cent. The survival rates paralleled the expected rate after 1.6 years but were found to be higher than expected after 2.8 years. The mortality after 1 year was 27 per cent, after 3 years 43 per cent and after 5 years 56 per cent.     

Dislocated Femoral Neck Fractures: A Follow-up Study of 98 Cases Treated by Multiple AO (ASIF) Cancellous Bone Screws

A series of 98 dislocated femoral neck fractures were treated by closed reduction and osteosynthesis with multiple AO (ASIF) cancellous bone screws. The patients were followed up for 2 years (or until death).

The degree of dislocation did not have a statistically significant influence on the failure rate, which was, however, significantly correlated with poor reduction. Thirty-nine per cent of the fractures were complicated by non-union or late segmental collapse.

Forty-three of the patients participated in the 2 year follow-up examination. Of these patients, 38 had achieved excellent or good hip function.

It was concluded that the reduction was the most important single factor in the treatment of these fractures.     

Antibiotic Prophylaxis in Open and Closed Fractures: A Controlled Clinical Trial

The value of prophylactic antibiotics in fracture surgery was studied in a series of 90 patients with open fractures of various bones and 180 patients with closed malleolar fractures treated by open surgery. Dicloxacillin and benzyl penicillin were compared to saline (placebo).

The soft tissue lesions of the open fractures were divided into Grade I wounds and Grade II & III wounds. Of the patients with Grade I wounds, 17 received dicloxacillin, 21 benzyl penicillin and 17 saline. No major infections occurred. Twelve patients with Grade II & III wounds were treated with dicloxacillin, 10 with benzyl penicillin and 13 with saline. In the saline group, 2 patients developed a deep infection.

Fifty-eight patients with closed malleolar fractures received dicloxacillin, 59 benzyl penicillin and 63 saline. Two infections developed in the placebo group. A statistically significant difference was found between the number of infections in the antibiotic groups and the number in the placebo group.

Superficial thromboplebitis following the antibiotic infusion occurred in 16 per cent of the dicloxacillin treated patients and in 1 per cent of those treated with benzyl penicillin or placebo.     

Osteomyelitis after Operative Fracture Treatment: A Report of 62 Cases Treated with Radical Surgery and Lincomycin (Lincocin®)

During the years 1967-1975 a total of 62 patients were treated for postoperative osteomyelitis. The lower extremities had been fractured in 89 per cent of the cases and 54 per cent were closed injuries. The fractures, mostly caused by traffic accidents and falls, had been immobilized by plates in 30 and by intramedullary nails or pins in 25 patients.

Staphylococcus aureus was cultured in 80 per cent, 68 per cent of them were resistant to penicillin, but in 84 per cent the organisms were highly lincomycin sensitive and only three patients with four osteomyelitic lesions presented lincomycin resistance.

The treatment consisted chiefly of sequestrectomies and saucerizations supported by 3-12 months of lincomycin treatment. In 30 operations a closed irrigation-suction technique was used, perfusing the wound with lincomycin solution. Stable implants should be left in place until the fracture is clinically solid whereas unstable osteosyntheses should be replaced by rigid internal or extraskeletal fixation.

At follow-up, the results were judged as good in 74 per cent, fair 8 per cent and poor 18 per cent. The amputation rate was 13 per cent.

Plates should not be used in the treatment of comminuted tibial fractures with considerable soft tissue damage.     

Skeletal Complications Following Renal Transplantation

The occurrence of skeletal complications was examined in a series of 204 renal graft recipients who had maintained graft function for more than 12 months. Osteonecrosis was observed in 22 of the patients (11 per cent) from 5 to 46 months after the transplant operation. The lesions were often multifocal, with as many as 40 joints affected. The most common site was the femoral head, necrosis of which was recorded in 24 instances. The lesions here present a major clinical problem, and total hip replacement was deemed necessary in 4 cases, in all of which an excellent result was achieved.

Fractures had occurred after the transplantation in 53 patients (26 per cent), against only 6 before the operation. A total of 109 fractures had been sustained after periods ranging from 1 to 58 months, the most common site being the pelvic bones. The fractures were treated according to standard principles; no complications were encountered.

The skeletal complications were equally common among the males and females; they tended to occur at advanced ages.

They occurred to roughly the same extent whether the graft was from a related or a cadaveric donor and whether the patient had received one or more grafts.     

Complications Following Osteotomy of the Greater Trochanter in Total Hip Replacement Arthroplasty Using the Lateral Approach

In a consecutive series of 365 hip replacement arthroplasties ad modum Charnley in 309 patients migration of the trochanteric fragment was encountered in 4.9 per cent of the cases.

The predisposing factors were wire-breakage, trochanteric fractures and excessive weight. Men were more apt than women to develop migration. Early mobilization with weight-bearing on the operated leg did not increase the risk of migration.

The migration rarely gave rise to complaints, and if so only mild ones.

Trochanteric union did not pose problems, and at the end of 2 years 98 per cent had united. After 5 years no case of non-union was detected.     

Mortality After Major Amputation Following Gangrene of the Lower Limb

Major amputations were performed on 310 patients because of gangrene of the lower limb. The mean age was 70 years and 58 per cent of the patients were males. Females were on average 5 years older.

The primary levels of amputation were above-knee (AK) in 33 per cent (103/310), through-knee (TK) in 21 per cent (66/310) and below-knee (BK) in 46 per cent (141/310).

Mortality during hospitalization was 18 per cent and the average hospitalization time 68 days. Mortality during hospital stay was primarily dependent on the occurrence of somatic complications, secondarily on the level of the amputation (as an expression of the extent of the gangrene) and finally on the age of the patient. The long-term survival rate was correlated primarily to the level of the amputation and secondarily to age. A high excess mortality was noted during the first few postoperative years, especially among AK amputees, but after this period the survival curve ran parallel to the expected survival rate. Mortality after 1 year was 34 per cent, comprising 17 per cent after BK amputation, 39 per cent after TK and 54 per cent after AK amputation.     

Thirty-year follow-up of ankle fractures

The natural course of ankle fractures was studied in 143 patients treated by closed methods. The average time elapsing from fracture to follow-up was 29 years. Eighty-two per cent had no radiographic signs of arthrosis; 83 per cent were free of symptoms. The most common fracture, supination eversion Stage II (49 cases), gave rise to minimal signs of arthrosis in only one patient, who had moderate symptoms.

The suggestion that all ankle fractures must be perfectly reduced is not supported by the findings of the present study.     

Femoral Neck Fractures: 165 Cases Treated by Multiple Percutaneous Pinning

A prospective series of 165 displaced subcapital fractures of the femoral neck treated with reduction and percutaneous multiple pinning is presented. the method offers the advantages of a short operating time, no loss of blood, immediate weight-bearing and no infection problems. Furthermore the operative procedure can be performed under local anaesthesia.

In Garden stage 3 fractures union occurred in 97 per cent and late segmental collapse in 8 per cent. in Garden stage 4 fractures union occurred in 72 per cent and late segmental collapse in 14 per cent.

Failures were almost exclusively encountered in the group of poorly reduced fractures which had a failure rate of 77 per cent.

In the case of non-union 75 per cent of the patients needed a secondary hip replacement whereas only 16 per cent of the patients with late segmental collapse had received an arthroplasty at the time of the follow-up.     

Studies on Mechanical Strength of Bone: I. Torsional Strength of Normal Rabbit Tibio-Fibular Bone

A method is described for testing torsional strength in small cortical bones at low velocities. The linearity and precision of the testing equipment, and the effect of the dimensions and chemical composition of the bone on torsional properties are analysed.

Rabbit tibio-fibular bones exhibited right-to-left differences in energy absorption capacity (up to 10.0 per cent), torsional rigidity (7.1 per cent), torque moment at fracture (6.3 per cent) and angular deformation (5.7 per cent). The scatter in energy absorption was more dependent on differences in angular deformation (strain) than on differences in torque moment (stress). No statistically significant dominance of either side could be observed.

The biomechanical properties of the bones were dependent on the body weight of the test animal and the transverse dimensions of the bone, but were not influenced by the small variations measured in the chemical composition of normal bone.     

Biochemical Changes in Bone Grafts Stabilized with Rigid Plates: I. Cancellous Grafts

The effect of rigid plate fixation on the chemical composition of cancellous interposition grafts was studied in rabbit tibio-fibular bones.

The concentrations of hexosamines and, to a lesser degree, of hydroxyproline and nitrogen, were high in the graft for the first 6 weeks, decreased from weeks 6 to 12, but remained higher than the corresponding values for the controls throughout the experiment (52 weeks). The ratio of hexosamines to hydroxyproline was highest for the graft at 3 weeks, indicating formation of cartilage and osteoid.

The initially low calcium concentration of the graft increased by 35 per cent from weeks 1 to 6, decreased from weeks 6 to 12, and remained below normal thereafter in comparison with corresponding values for the cortical host bone. The ratio of calcium to hydroxyproline increased throughout the experiment, reflecting maturation of the graft to lamellar bone.

Thus, biochemically the early incorporation of rigidly fixed cancellous interposition grafts resembles the healing of unimmobilized fractures by callus formation.     

Risk factors for deep venous thrombosis in tetraparesic mentally retarded patients

Objectives : The risk factors and incidence of deep venous thrombosis were studied in a population of para- and tetraparesic patients institutionalized for long durations.

Methods : Retrospectively, the antecedents and risk factors of deep venous thrombosis were collected for each patient.

Results : Data were available for 57 patients. The mean duration of hospitalization was 18 years. None of the patients presented thromboembolic pathology. Ninety-three per cent of the patients were spastic tetraparesic, 7% were spastic paraparesic. Sixty per cent of the patients presented added risk factors, mostly orthopaedic surgery, bone fractures and hormonal treatments.

Conclusion : Spasticity probably plays a role in preventing deep venous thrombosis in paralysed patients, but it does not fully explain the absence of deep venous thrombosis in this population.     

Posterior Fusion of the Lumbosacral Spine: Evaluation of the Operative Results and the Factors Influencing Them

The operative results of 79 patients subjected to posterior fusion of the lumbosacral spine were evaluated on the basis of a follow-up examination performed on average 5.4 years after operation. A method of evaluation was developed which measured the patients' subjective improvement and working capacity. The method proved appropriate for clinical use and gave a more correct picture of the operative result than methods relying on the patient's own opinion or the radiographic assessment as the only criterion. Sixty per cent of the patients were subjectively improved, 40 per cent had returned to their previous or a corresponding occupation and 24 per cent had a good operative result, assessed by the method applied.

A statistical analysis was performed in order to find the factors influencing the operative results. Age over 40 years, heavy or moderately heavy preoperative work and over 6 months' preoperative disability had a statistically significant, unfavourable effect on the results. In the case of labourers in heavy occupations, working capacity was seldom restored to a degree sufficient for return to their previous work.

The operative technique proved reliable with 91 per cent successful fusions, assessed from functional radiographs. Successful fusion did not imply a good operative result, although it did so more often than non-fusion.

On the basis of this study, operative fusion of the lumbosacral spine seems to be of relatively little value in the treatment of patients suffering from low back pain, and factors other than purely medical or surgical have a considerable influence on the operative results.     

Clinical and Social Status Following Injury to the Lateral Ligaments of the Ankle Follow-up of 144 Patients Treated Conservatively

Out of 174 patients treated conservatively for injuries to the lateral ligaments of the ankle 144 were seen at follow-up after 3.1-6.1 years (mean 4.2 years), and clinical as well as social sequelae were recorded. The diagnostic criterion was a difference in talar tilt of 6 or more degrees between the injured and uninjured foot on inversion stress radiographs.

Occupational and athletic injuries, almost equally represented, made up a total of 64 per cent. Residual symptoms were present in 21 per cent, mainly in the form of functional instability, but only four patients (3 per cent) reported daily complaints. One patient had developed reflex dystrophy, and this was the only patient who had been referred for further orthopaedic treatment. There was a close correlation between pain on movement in the ankle joint and residual symptoms which were, incidentally, unrelated to the degree of primary talar tilt. All the patients seen at follow-up had normal range of movement in the talocrural and subtalar joints. Two patients with residual symptoms had stopped working, while in the others the working ability was unaffected.

The period off work had been twice as long for patients having heavy and fairly heavy work as for those doing light work. All football players with residual symptoms had had to give up playing, but only a few had daily complaints. This indicates that some symptom-free patients have in fact latent symptoms, elicited only by fairly severe strain.     

Vitamin D Metabolism and Osteomalacia in Patients with Fractures of the Proximal Femur

A high frequency of histological osteomalacia (25 per cent) was seen in patients with fractures of the proximal femur. No correlation was found between the levels of circulating 25-hydroxyvitamin D (25-OHD) or 1,25-dihydroxyvitamin D (1,25-(OH)₂D) and the bone histomorphometric changes.

The serum 25-OHD levels were normal, which excludes a dietary vitamin D deficiency or a reduced hepatic hydroxylation of the vitamin. The mean serum 1,25-(OH)₂D concentration was significantly reduced in the whole patient group, but surprisingly the levels were normal in those with histological osteomalacia, indicating that an impaired conversion of 25-OHD to 1,25-(OH)₂D was not the primary cause of the bone disease. A reduced sensitivity to 1,25-(OH)₂D might be a possible explanation for the osteomalacia.     

Costs of Treatment of hip Fractures: A Calculation of the Consumption of the Resources of Hospitals and Rehabilitation Institutions

A series of 518 patients with hip fractures and a median age of 78 years was followed for 6 months. on admission to hospital the patients were assessed and were found to be evenly distributed among four social function groups according to their level of dependence on the social welfare system. At the 6 months follow-up the mortality rate was about 16 per cent, leaving 437 patients for a reassessment of social function.

The average hospitalization time was 23 days; thus 17 per cent of all orthopaedic hospital beds in the area were occupied by patients with hip fractures. Patients staying the longest time in hospital were those waiting for discharge to a nursing home. the average stay in rehabilitation institutions was 71 days. the total rehabilitation course was longest for the most dependent patients.

The risk of death or deterioration of social function among patients admitted from home was 48 per cent. in the case of social deterioration or technical failure following the fracture treatment the total rehabilitation course was considerably prolonged.

The resources required for the treatment of hip fractures in a suburban area of 500,000 inhabitants were calculated to be 32 hospital beds, 43 rehabilitation beds and at least 21 nursing home beds.     

Femoral Neck Fractures in Young Adults

A total of 110 fractures of the neck of femur were studied in 108 patients 17 to 50 years old. The aims were to analyze why these fractures occur in young adults, and what results can be expected after internal fixation.

Severe trauma caused about half of the fractures. In the remaining group chronic and disabling disorders were usually present at the time of injury. Seventeen patients were known to abuse alcohol. Aseptic necrosis with late segmental collapse occurred in 41 per cent of the hips (45/110), comparatively more often in patients who were 45 years or younger. Only 16 of the 73 patients who were seen at follow-up (22 per cent) had a perfect result.

It is concluded that femoral neck fractures in patients younger than 45 years occur because of significant trauma in a healthy subject, or minor trauma in a subject with predisposing disease. The incidence of late segmental collapse is greater than in elderly patients with femoral neck fractures. A less satisfactory result can therefore be expected.     

Hip Joint Instability After the Neonatal Period: Diagnosis and Treatment of 20 Consecutive Cases

A consecutive series of 20 children (21 hips) with idiopathic hip joint instability, diagnosed after the neonatal period, is presented. The diagnosis was confirmed by hip joint arthrography. In all the children, 1.5-21 months old at the time of diagnosis, closed reduction could be achieved. They were treated in plaster directly or after treatment of contractures in the adductor muscles of the hip joint.

Stability was rapidly attained during plaster treatment.

The results of the treatment in plaster were checked by a second arthrography in two thirds of the cases, and all cases have been clinically and radiologically evaluated 1-4.5 years after diagnosis. All of the children developed clinically stable hips and they walk normally. In two hips signs of avascular necrosis of the femoral head were found and in three hips (two children) the skeletal development was markedly delayed. In 81 per cent (17/21 hips) the prognosis was considered good; it is uncertain in the remaining four hips.

The appropriate period of fixation in plaster related to the age of the child is discussed.     

Consumption of hospital resources for femoral neck fracture

In 1,673 patients with femoral neck fracture, the utilization of hospital and rehabilitation resources following primary operations and necessary reoperations was assessed in relation to type of treatment center and outcome of the fracture. All the patients were admitted from their homes to either orthopedic or general surgery departments, urban or rural/The fractures were treated by one of four osteosynthesis methods and followed for 6 years postoperatively.

About 30 per cent of the fractures developed healing complications. Patients treated in surgical departments utilized more acute and rehabilitation bed days than those treated in orthopedic departments. The patients stayed longer in city surgical departments than in rural surgical departments.

The Thornton osteosynthesis used by general surgical specialists resulted in 29 percent, mainly early complications, whereas the Rydell osteosynthesis used by orthopedic specialists had 24 percent, mainly late complications. This difference resulted in more than 40 percent higher consumption of bed days by the Thornton-nailed patient.

In sum, a fracture without complications consumed, on an average, 31 cost standardized bed days compared with 101 bed days for fracture with complications. Thus, every fracture with complications was SEK 112,000 more expensive than the complication-free one.