Primary Prosthetic Replacement Research Articles

Minimalosteosynthese proximaler Humerusfrakturen mit intramedullärer Titanwendel

Nach wie vor stellt die dislozierte oder instabile proximale Humerusfraktur ein unzureichend gelöstes Problem dar. Die Literatur beschreibt viele unterschiedliche Behandlungsrichtlinien entsprechend der Fraktureinteilung. Diese erstrecken sich von der konservativ-funktionellen Therapie über geschlossene oder offene Reposition, von der Implantation unterschiedlichen Osteosynthesematerials über den primär prothetischen Ersatz des Humeruskopfes. Im Zeitraum von November 1998 bis November 2000 wurden an unseren Kliniken 38 Patienten mit Zwei-, Drei- und Viersegmentfrakturen des proximalen Humerus mit einem neuen, viel versprechenden minimalinvasiven Osteosyntheseverfahren - der intramedullären Titanwendel - behandelt und postoperativ klinisch und radiologisch nachkontrolliert. Unsere 1-Jahres-Ergebnisse umfassten 12 sehr gute, 12 gute, 7 befriedigende und 5 schlechte funktionelle Ergebnisse (Durchschnitt im Constant Score 75 Punkte, im UCLA-Score 30,6 Punkte). Der Artikel beschreibt die Vorgehensweise, Ergebnisse und spezifischen Probleme dieser Behandlungsweise im Vergleich mit anderen Osteosyntheseverfahren.

Four-Part Fractures of the Humeral Head: Clinical Results of Primary Hemiarthroplasty

In 52 patients with 4-part fractures of the proximal humerus, primary prosthetic replacement of the humeral head was performed. The median age of the mainly female group of patients was 77 years. According to the Neer fracture classification, IV/4 and V/4 fractures were predominant. Subjective evaluation of the treatment results yielded good to very good results in 2/3 of the cases according to the Visual Score. The Constant Score median was 59 points (range: 40 -91 points), with our patients achieving better results for the subjective parameters pain and activity than for the objective parameters mobility and strength. Sonographic examination revealed in nearly all patients atrophied rotator cuffs associated with motor disturbance between the gliding layers. As a result of their trauma, 4 patients suffered from a persistent damage of the brachial plexus, in 1 patient a secondary dislocation of the tubercula resulted, and 2 patients developed a deep infection.

Blood loss in prosthetic hip replacement is not influenced by the AB0 blood group.

To find out if there is a correlation between AB0 type and the amount of blood lost at operation. Retrospective study. One county and one university hospital, Sweden. 540 patients who underwent primary prosthetic hip replacement under regional anaesthesia. Albumin (n = 298) or dextran (n = 242) were used as plasma substitutes. Estimated blood loss and number of units of red cell concentrates transfused. The characteristics of the study groups were similar. In patients given albumin, the mean (SD) intraoperative loss with blood group 0 (n = 100) was 718 (413) ml and 2.7 (1.9) red cell units were given. Those with other blood groups (n = 198) lost 713 (469) ml and were given 2.5 (2.0) units. In patients given dextran with blood group 0 (n = 82), the intraoperative blood loss was 650 (337) ml, the postoperative loss 480 (222) ml and they received 2.1 (2.1) units. The corresponding values in the patients with other blood groups (n = 160) were 665 (351), 498 (208) and 2.5 (2.1) units. Blood group 0 was not associated with increased blood loss.

Fractures involving splitting of the humeral head.

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable.

Fractures involving splitting of the humeral head

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable.

Comminuted humeral head fractures: a multicenter analysis.

Three centers' experience with 93 comminuted humeral head fractures were clinically (Constant score) and radiologically (Neer) analyzed. The results revealed fundamental differences between the various types of fractures depending on the number of fragments. For three-part fractures open reduction and internal fixation (mean Constant scores 83 and 91 points, respectively) or conservative treatment (78 points) seem to be indicated. The prognosis for four-part fractures is determined largely by the vascular supply of the head fragment with a high risk of humeral head osteonecrosis. For this reason primary prosthetic replacement (mean Constant score, 74 points compared with 54 points for conservative treatment and 52 points for open reduction) should be recommended for this type of fracture. In conclusion, we stress the importance of fracture type directing the therapeutic modality.

The Proximal Humeral Fractures Treated by the Primary Prosthetic Replacement: A Report of 3 Cases

The Proximal Humeral Fractures Treated by the Primary Prosthetic Replacement: A Report of 3 Cases

Correlation of 99mTc-MDP scintimetry and histology in cervical hip fracture.

In 20 cases of fresh cervical hip fracture, treated with primary prosthetic replacement, preoperative 99mTc-MDP scintimetry was compared with histologic findings of the extracted femoral heads. The radionuclide uptake was classified into three types according to the activity distribution; overall increase, focal decrease, and overall decrease. Histologically, the location and extent of ischemic necrosis in the femoral heads were closely related to the distribution of decreased activity.

Acetabular erosion: a comparison between the Austin Moore and Monk hard top prostheses

Primary prosthetic replacement has become the method of treatment for acute subcapital fractures of the femur and is now widely accepted as a treatment for elderly patients. This paper presents the incidence of acetabular erosion by Monk (hard top) hip prostheses for subcapital fractures as compared with that by Austin Moore prostheses.

Parathormone, Calcitonin, and Vitamin D Metabolites During Normal Fracture Healing in Geriatric Patients

In order to study the role of calcium-regulating hormones during callus formation in elderly patients, serum levels of parathormone (PTH), calcitonin (CT), 25-hydroxyvitamin D [25-OH-D], 1,25-dihydroxyvitamin D [1,25(OH)2D], 24,25-dihydroxyvitamin D [24,25(OH)2D], and calcium (Ca) were determined in 41 patients with fractures of long bones, primarily hip fractures. The parameters were measured on admission and after eight weeks. There were almost no changes in hormone serum levels during bone repair, except for a decrease in serum levels of 1,25(OH)2D from 25.3 +/- 2.3 pg/ml on admission to 21.0 +/- 2.0 pg/ml eight weeks later (p less than .001). Patients with fractures compared to normal elderly humans have lower serum levels of PTH (0.99 +/- 0.06 ng/ml versus 1.88 +/- 0.34 ng/ml; p less than .001), 25-OH-D (10.7 +/- 1.0 ng/ml versus 17.1 +/- 1.8 ng/ml; p less than .001), and Ca (9.1 +/- 0.1 mg% versus 9.7 +/- 0.1 mg%; p less than .001) and higher serum levels of 1,25(OH)2D (25.3 +/- 2.3 pg/ml versus 17.1 +/- 2.3 pg/ml; p less than .001). Female patients have lower serum levels of 24,25(OH)2D compared to males (1.65 +/- 0.15 ng/ml versus 2.06 +/- 0.29 ng/ml; p less than .05). A similar trend was noted in serum CT levels during callus formation (0.12 +/- 0.02 ng/ml versus 0.16 +/- 0.02 ng/ml; p less than .05). Patients with subcapital fractures of the femur have significantly lower serum levels of all vitamin D metabolites on admission, compared with patients suffering from extracapsular fractures.(ABSTRACT TRUNCATED AT 250 WORDS)

Femoral neck fractures in the geriatric population: the influence of perioperative health upon the selection of surgical treatment.

The use of a primary prosthetic replacement such as an Austin-Moore hemi-arthroplasty in patients sustaining fractures of the femoral neck has been associated with increased post-operative medical morbidity and mortality. A retrospective review was performed using the medical records of patients greater than 59 years of age who sustained femoral neck fractures and were treated with either internal fixation or primary hemi-arthroplastic replacement at Loyola University Medical Center between 1969 and 1979. Peri-operative data were reviewed and evaluated using computer-aided statistical analysis. Comparing the two forms of surgical treatment, statistically significant factors associated with primary hemi-arthroplastic replacement included: pre-injury nursing home residence, pre-injury ambulation requiring assistance, age greater than 79 years, slight elevation in serum creatinine values, abnormal electrocardiograms in patients over 77 years of age, time from injury to surgery of four or more days, and the use of spinal anesthesia (P less than 0.05). Factors associated with internal fixation were: patient age of 79 years or less, independent ambulation, non-nursing home residence, normal lab values, normal EKGs, less than four days from injury to surgery, and the use of general anesthesia. Within the limits imposed by a retrospective review in this specific patient population, there appears to be a tendency for older, less healthy patients to have been treated with primary hemi-arthroplasty. Possibly the previously reported increased post-operative medical morbidity and mortality associated with this procedure, as compared with internal fixation, may be a result of biased patient selection, and not a fault of the procedure.

Post-traumatic avascular necrosis of the humeral head in displaced proximal humeral fractures.

Nineteen patients with displaced four-part fracture or fracture-dislocation of the proximal humerus were retrospectively studied to investigate the incidence of avascular necrosis and its clinical importance. The average followup duration was 23.6 months. No incidence of avascular necrosis of the humeral head with subchondral collapse was found. Four patients were found to have coarse trabeculae suggesting a revascularized humeral head which probably had become necrotic after the trauma. The treatment of choice for displaced four-part fracture or fracture-dislocation of the proximal humeral is early adequate open reduction and internal fixation rather than primary prosthetic replacement. The authors believe that a majority of the humeral heads in this injury develop avascular necrosis, but most of the humeral heads are quickly revascularized with creeping substitution.

Should We Abandon Primary Prosthetic Replacement for Fresh Displaced Fractures of the Neck of the Femur?

The complications and results of 100 patients with a displaced femoral neck fracture, treated by primary prosthetic arthroplasty between 1972 and 1977, demonstrate a high morbidity from the surgical procedure. The six-month mortality was 20%. Good results were obtained in only 28% of the patients. In view of the reported incidence of deep-wound infection, dislocation and high mortality at six months, arguments are presented for and against the routine use of cemented hemiarthroplasty. Further consideration should now be given to alternative procedures, such as the muscle-pedicle graft. Total hip replacement may be indicated in some patients in whom accurate reduction of a displaced femoral neck fracture is impossible.

Survival patterns following primary prosthetic replacement for acute femoral neck fractures in the elderly.

Theoretical statistical models have been used to study survival patterns following primary prosthetic replacement for acute femoral neck fractures in the elderly with special emphasis on the nature of the potential excess mortality following trauma and operation. The chances of our patients surviving given periods of time are well below those of the standard population. The excess mortality has been quantified using the proportional hazard model. The high death rate for our patients is limited to the first 4-6 postoperative months, thereafter the death rate is similar to that of the standard population. Similarly we can show that mortality following surgery is primarily dependent on the age of the patient. Survival probability and expected longevity have been calculated for different age groups. The relative longevity expected for patients below the age of 70 is very good compared with a very reduced expected longevity for patients older than 90 years. The practical consequences of our findings are discussed.

Internal fixation versus endoprosthesis in the treatment of femoral neck fractures in the elderly. A prospective analysis of the comparative costs and the consumption of hospital resources.

The consumption of hospital resources and the costs involved in treating femoral neck fractures in the elderly were studied and a comparison was made between internal fixation (von Bahr screws) and primary prosthetic replacement (Christiansen's endoprosthesis). The 1-year results of screw fixation were excellent or good in 55% of the patients, fair in 17% and poor in 28%, compared with 79% excellent or good results, 13% fair and 8% poor results in the prosthetic group. As regards the initial stay in hospital, prosthetic replacement was found to be associated with 2.4 times higher costs. This difference was reduced, however, by a more expensive follow-up and more frequent readmissions and reoperations in the internal fixation group. Considering the total costs, prosthetic replacement was found to be 1.6 times more expensive than internal fixation.

Subcapital fractures of the femur in rheumatoid arthritis

A review of 40 subcapital fractures of the femur in 37 patients with rheumatoid arthritis has shown that no displaced fracture treated by reduction and fixation united, even when it had been acceptably reduced and fixed. Primary prosthetic replacement of the femoral head gave significantly better results, at least in the short term. A postoperative deep infection rate for prosthetic replacement of one in five was reduced to zero by prophylactic antibiotics: current treatment with oral corticosteroids did not increase the risk of infection. The possibility of a stress fracture of the femoral neck should be considered if a patient with chronic rheumatoid arthritis presents with increasing hip pain after minimal trauma.

A New Design of the Christiansen Endoprosthesis:Report of Two Cases in Which Separation of the Two Components of the Prosthetic Head Occurred

Primary prosthetic replacement in elderly patients with displaced intracapsular fracture of the femoral neck has been used during the last few years with encouraging early results. The prosthetic device preferred has been Christiansen's endoprosthesis. During the past year a new type with separable plastic head and metallic cap has been used. This modification has resulted in the occurrence of a previously unknown complication, a separation of these two parts, necessitating reoperation and insertion of a new head piece. The possible mechanisms causing this separation are discussed.

Primary prosthetic replacement in acute femoral neck fractures

This paper reports a retrospective study of acute femoral neck fractures in 123 patients treated by primary prosthetic replacement. The average age in our patient population was 80.5 years. A Christiansen trunnion-bearing hip prosthesis (Christiansen, 1969 and 1974) was used in all patients except one. The prosthesis was cemented to the femoral shaft. The postoperative mortality rate was low, and the mortality rate was 8.7 per cent. The patients were examined between 6 months and 3 1 2 years after operation. Excellent or good results according to Stinchfield's hip assessment system (Stinchfield et al., 1957) were obtained in 82 per cent of the patients. We suggest that primary prosthetic replacement in acute femoral neck fractures in elderly patients is a safe and valuable procedure. However, a definite conclusion concerning this therapy cannot be drawn before a prospective study comparing the results of internal fixation and primary prosthetic replacement is made.

A survey of fractures of the proximal femur

A series of 1494 fractures of the proximal femur, admitted over a 68-month period to the North East Area Accident Unit, is presented. The mortality for the series was 18 per cent, with operative mortality varying according to the fracture site and the method of treatment, being 18.1 per cent for extracapsular fractures, 14 per cent for Smith-Petersen nailing of intracapsular fractures, and 31 per cent for primary prosthetic replacement. In general terms, morbidity and mortality were proportional to age and to pre-existing general medical conditions. The results are presented in full, and are compared with other published series.

Para-articular ossifications after primary prosthetic replacement ad modum Austin T. Moore.

This study concerns the frequency of para-articular ossifications after primary prosthetic replacement ad modum Austin T. Moore in the treatment of unstable fractures of the femoral neck. In 121 patients who were X-rayed after surgery ossifications were found in 45 per cent of the cases. Patients that preoperatively had severe coxarthritis or rheumatoid arthritis are excluded. Two thirds of the bone formations described were very small and without clinical importance. About 20 per cent of the ossifications were of a considerable size, but no clinical consequences could be demonstrated. About 12 per cent of the ossifications--6 per cent of all the patients in this study--were large, and only in this group could a compromised hip function be found. It seems as the process of ossification is limited to the first 3 postoperative months. There is a good correlation between the communications regarding ectopic bone formation after total hip replacement and the frequency found in this study.