Biomedical subjects
Publications and source records attributed to M C Forster.
The treatment of distal femoral fractures has evolved; nevertheless, these fractures remain difficult to treat and carry an unpredictable prognosis. Over the years, many different strategies have been used with varying success. This review outlines the problems presented by distal femoral fractures and the results of current surgical techniques.
A systematic review was performed to assess the relative merits of reamed and unreamed antegrade femoral nailing. To be included, a study had to be prospective, randomised or pseudorandomised, comparing reamed and unreamed antegrade femoral nailing in adults. Where more than one study from the same institution was available, only the study with longest follow-up was included. A literature search found 2044 possible articles. Of these, eight studies compared reamed and unreamed femoral nailing. The methodology of these articles was independently assessed by all the three authors. Five studies met the inclusion criteria. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present, the data were not combined. If there was no significant heterogeneity, a combined odds ratio or weighted mean difference was calculated using a fixed effects model, and a Z-test was performed to test the overall effect. Six hundred and forty-seven femoral fractures (315 reamed; 332 unreamed) were entered into the included studies. Unreamed nailing was quicker and associated with significantly less blood loss (P < 0.00001). Reaming significantly reduced the time to union (P = 0.00001), non-union (P = 0.002), delayed union (P = 0.005), technical problems (P = 0.01) and reoperation rate (P = 0.001). The use of reamed femoral nails gives significant advantages over unreamed femoral nails.
A systematic review was performed to assess reamed and unreamed tibial nailing. Only prospective, randomised studies comparing reamed and unreamed tibial nailing in adults were included. A literature search found 1200 possible articles. There were seven comparative studies. These articles were independently assessed by all three authors. Three studies met the inclusion criteria. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present, data from the studies was not combined. If there was no significant heterogeneity, a combined odds ratio was calculated using a fixed effects model and a Z-test was performed to test the overall effect. Two hundred and ninety-one tibial shaft fractures were entered into the included studies. Two hundred and eighty (96%) were followed up (148 reamed; 132 unreamed). There was an increased non-union rate when the tibia was not reamed (p = 0.02). Screw breakage was more common in the unreamed group (p<0.0001). This study could find little difference in the incidence of other complications following reamed or unreamed tibial nailing.
A systematic review was performed to determine the advantages and disadvantages of patellar resurfacing during total knee replacement for osteoarthritis. Three randomised controlled studies were analysed. These studies recruited 302 knees and 235 knees (78%) were reviewed at least 5 years postoperatively (range 5 10 years). Patients undergoing patellar resurfacing received a cemented all polyethylene patella component. A patelloplasty was performed in some of the unresurfaced knees. For the dichotomous data, odds ratios and 95% confidence intervals were calculated. Each outcome measure tested was assessed for heterogeneity using the Cochran Q test. If significant heterogeneity was present (p < 0.10), data from the studies were not combined. If there was no significant heterogeneity, a combined odds ratio was calculated using a fixed effects model and a Z test was performed to test the overall effect. Reoperation for patellofemoral problems was significantly more likely in the unresurfaced group (p = 0.003). The overall rate for reoperation for a patellofemoral problem was 0.7% in the resurfaced group and 11% in the unresurfaced group. Study data on anterior knee pain could not be analysed together as there was significant heterogeneity. There was no difference between the two groups in terms of revision. This study found no mid- to long-term benefit to leaving the patella unresurfaced.
Thirty-eight patients with symptomatic knee osteoarthritis without mechanical symptoms were randomised after informed consent to receive either a course of intra-articular Hyalgan injections or an arthroscopic washout. The patients were prospectively assessed pre-intervention, 6 weeks, 3 months, 6 months and 1 year using a 10 cm visual analogue pain score, the Knee Society function score and the Lequesne index. There was no significant difference between the two groups at 6 weeks, 3 months, 6 months or 1 year. The use of intra-articular Hyalgan injections in patients with knee osteoarthritis without mechanical symptoms gives results comparable with arthroscopic washout. Hyalgan is an alternative to arthroscopy in this patient group. Further study is needed to confirm these findings and improve patient selection.
Although the first meniscal repair was performed over 100 years ago, many aspects of meniscal repair remain controversial. This article reviews the structure and function of the menisci, the rationale for repair and the clinical results of arthroscopic meniscal repair.
Both posterior stabilization and metal backing of the tibial component are design changes that could alter the longevity of total knee arthroplasties (TKAs). Survival analysis data from 16 articles (5,950 knees) were combined to compare design features. No difference was found in survival between posterior stabilized implants and implants that were not stabilized or between metal-backed and all-polyethylene tibial components. Those all-polyethylene tibial components that were not stabilized showed significantly better survival than metal-backed, nonstabilized tibial components and posterior stabilized, metal-backed components (P<.05) but not posterior stabilized, all-polyethylene components. According to the currently available literature, posterior stabilization or metal backing of the tibial component does not improve the longevity of primary cemented fixed bearing condylar-type TKAs.
The analgesia received in the 1st week of treatment by 100 consecutive acute hip fracture patients (88 female) was prospectively studied. A modified mental test was performed on all patients prior to surgery. Patients with cognitive impairment (modified mental score <5) received only 74% of the paracetamol, 43% of the non-steroidal anti-inflammatory drugs (NSAIDs), 52% of the opioid and 64% of the morphine that cognitively intact patients received. These differences were significant for paracetamol (Mann-Whitney test; p=0.001) and opioid (Mann-Whitney test; p=0. 0012) but not for NSAIDs or morphine. Either hip fracture patients with a reduced mental score perceive less pain than their more cognisant peers, or the treating clinicians perceive their pain as less, or both.
Although the number of centenarians in our population is increasing, mortality rates following hip fracture in this group of patients has not yet been reported. The medical records of a consecutive series of 13 centenarians with proximal femoral fractures who presented to the Derbyshire Royal Infirmary over a 20 year period were retrospectively reviewed. The majority of patients were female (M:F 2:11) and had suffered intertrochanteric fractures. The recorded incidence of surgical complications was low. The mortality at 30 days, 6 months and 1 year were 31%, 50% and 56%, respectively representing a 20% increase in mortality at 1 year when compared to the expected mortality rates among their non-injured peers. When compared with over 1000 hip fracture patients of all ages in previous prospective studies, the centenarians in this series were found to have a significantly higher mortality during hospital admission (p<0.001) and at 1 year (p=0.002). The treatment of hip fractures in centenarians poses a challenge. Optimal anaesthesia, expeditious surgery and a co-ordinated multidisciplinary approach to care is essential in these patients.
A consecutive series of 43 patients (44 elbows) underwent ulnohumeral debridement for elbow osteoarthritis. Thirty-five patients (36 elbows) were reviewed after a mean follow-up of 39 months. Eighty-one percent of patients were satisfied, with 12 good, 19 fair, and 5 poor outcomes. The mean flexion/extension arc, pain score, and locking were all significantly improved, but a significant number of patients had rest pain. Patients who had symptoms for less than 2 years, considerable preoperative pain, or cubital tunnel syndrome had a significantly increased chance of a good outcome. The absence of preoperative locking was associated with a significantly increased chance of a poor outcome. A history of trauma, preoperative range of movement, and radiograph score did not predict outcome.