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Background Tension band wiring is the most common surgical procedure for fixation of fractures of the olecranon, but symptomatic hardware prominence and migration of K-wires can cause a high re-operation rate. The olecranon sled has been designed to minimize some of these problems. Material and methods Simulated olecranon fractures were created in 6 matched pairs of cadaver arms. Each pair was fixed with tension band wiring used on the one arm and the olecranon sled being used on the other. Mechanical testing was done with the humerus rigidly fixed in a vertical position while the forearm was held at 1 of 3 angles of elbow fixation, 45 degrees , 90 degrees and 135 degrees , respectively. For each angle, the triceps and the brachialis muscles were sequentially loaded with 5 kg (50 N) for 20 cycles and the amount of fracture displacement measured. Results Loading of the brachialis muscle produced no increase in the fracture gap for either of the two fixation techniques. However, an increase in the fracture gap of up to 0.23 mm was found after cyclic loading of the triceps muscle for both techniques. The amount of increase was not significantly different between the two techniques. Interpretation The olecranon sled appears to provide as stable fixation as tension band wiring for olecranon fractures. [ABSTRACT FROM AUTHOR]

Purpose : To review what predictors are of positive or negative value in the rehabilitation procedure following hip fractures. Method : Reviewing a doctorial thesis on prognosis and rehabilitation of elderly with a hip fracture from 1980 and then review the literature on this subject for the following quarter of a century. Results : In the Western world the short-term prognosis for early return home after sustaining a hip fracture depends on the success of the operation allowing independent walking and basic activities of daily life, no debilitating disease and having someone at home. The one-year prognosis for having returned and remained at home requires a reasonable good health irrespective of living alone and a somewhat deteriorated hip function. Conclusions : It is difficult to make comparisons with studies of other populations and other time periods. Different predictors of the rehabilitation are used and the definitions of these are not always the same. They are of varying weight, can change with time and may be interdependent of each other. For example, general medical condition and age are strongly interrelated predictors but age alone is less important than concomitant disease for the success of the rehabilitation. Nevertheless, already on admission of a patient with a fresh hip fracture a reliable prognosis can be done. However, such a prediction must be guided by ethical, social and scientific concerns. [ABSTRACT FROM AUTHOR]

Background and Purpose: The Hansson Twin Hook (HTH) is an alternative to the lag screw in the treatment of trochanteric fractures. In osteoporotic bone, mechanical tests have indicated that the HTH has better fixation properties than the lag screw. We evaluated the fixation stability of the HTH in a large series of elderly patients with trochanteric fractures. Many surgeons were involved in assessment of whether the device was user-friendly., Patients and Methods: In a prospective bicentric study, 55 surgeons used the HTH and a standard plate in 157 consecutive patients with trochanteric fractures, 83% of which were unstable. The mean age of the patients was 83 (43-98) years. They were followed regularly clinically and radiographically for at least 4 months, with a radiographic file search at 2 years., Results: Technical errors occurred intraoperatively in 7 cases. The reduction of the fracture was inaccurate in these patients; thus, the HTH had not been placed centrally in the femoral head. One of these errors was immediately and easily corrected without interference with the standard plate, and caused no further problems. 2 of the remaining 6 intraoperative errors developed into failures of fixation during the 2-year period., Interpretation: The HTH gives adequate fixation in the bone of elderly patients with trochanteric fractures and has a low failure rate. It is also easy to use.

Background and Purpose: Few economic or quality-of-life studies have investigated the long-term consequences of fragility fractures. This prospective observational data collection study assessed the cost and quality of life related to hip, vertebral, and wrist fracture 13-18 months after the fracture, based on 684 patients surviving 18 months after fracture., Patients and Methods: Data regarding resource use and quality of life related to fractures was collected using questionnaires at 7 research centers in Sweden. Information was collected using patient records, register sources, and by asking the patient. Quality of life was estimated using the EQ-5D questionnaire. Direct and indirect costs were estimated from a societal standpoint., Results: The mean fracture-related cost 13-18 months after a hip, vertebral, or wrist fracture were estimated to be euro2,422, euro3,628, and euro316, respectively. Between 12 and 18 months after hip, vertebral, and wrist fracture, utility increased by 0.03, 0.05, and 0.02, respectively. Compared to prefracture levels, the mean loss in quality of life between 13 and 18 months after fracture was estimated to be 0.05, 0.11, and 0.005 for hip, vertebral, and wrist fracture., Interpretation: The sample of vertebral fracture patients was fairly small and included a high proportion of fractures leading to hospitalization, but the results indicate higher long-term costs and greater loss in quality of life related to vertebral fracture than previously believed.

We compared the efficacy of the Medoff sliding plate (MSP) with 3 other screw-plate systems for fixation of unstable intertrochanteric fractures in a randomized multicenter trial of 569 elderly patients. The MSP has biaxial dynamic capacity along both the neck and the shaft of the femur unlike the other systems, which lack dynamic capacity along the shaft. 268 fractures were operated on with the MSP, and 301 with the dynamic hip screw (DHS), with or without a trochanteric stabilizing plate (DHS/TSP) or with the dynamic condylar screw (DCS). The MSP had recently been shown to the surgeons. The patients in the groups were similar as regards age, domestic situation, preinjury walking ability and type of fracture. We followed the patients clinically and radiographically for at least 1 year. There was no significant difference in walking ability at follow-up or rate of return to home. Fixation failure occurred in 18/268 fractures operated on with the MSP, in 8/238 with the DHS, in 3/49 with the DHS/TSP and in 1/14 with the DCS. The difference in the rate of fixation failure was not statistically significant when the MSP group was compared to the 3 other groups. In 14 of the 18 fixation failures in the MSP group, the biaxial dynamic capacity of the MSP had not been used due to technical errors by surgeons, unfamiliar with the new method. No selection bias was found regarding fracture types in the 2 subgroups of patients with correct or inadequate biaxial dynamization. Extramedullary fixation of unstable intertrochanteric fractures with these implants showed a low failure rate. When using the MSP, biaxial dynamization must be correctly performed.

We compared the efficacy of a load-sharing device, the Medoff sliding plate (MSP), with that of 3 other load-bearing screw-plate devices for the fixation of subtrochanteric fractures in a randomized multicenter trial of 107 elderly patients. 55 fractures were operated on with the MSP, and 52 with the dynamic hip screw (DHS) with or without a trochanteric stabilizing plate (TSP) or with the dynamic condylar screw (DCS). The patient material in the groups was similar regarding age, domestic situation, preinjury walking ability and fracture types. We followed the patients clinically and radiographically for a minimum of 1 year. There was no significant difference in walking ability or return rate to the home at follow-up. Fixation failure occurred in 1/55 fractures operated on with the MSP, in 3/32 with the DHS, in 3/12 with the DCS and in 2/8 with the DHS/TSR The difference in the rate of fixation failure was statistically significant, when the MSP group was compared to the 3 load-bearing devices in the other group (1 vs 8). On the basis of this experience, we think that the load-sharing principle of the MSP, which seems to facilitate fracture impaction and stability, appears to be a good alternative in extramedullary fixation of subtrochanteric fractures.

We compared two different subtrochanteric fracture fixation techniques, an intramedullary hip screw system (IMHS) and an extramedullary, dual sliding screw-plate system (MSP), to determine relative fixation stability. 6 matched pairs of osteosynthesized osteopenic cadaver femurs were axially loaded to 1000 N with concurrent, simulated abductor forces of 0%, 50%, or 86% of the applied head force. The initial loading sequence was made with uniaxial dynamization--the lag screw of the MSP locked and distal locking of the IMHS nail. Femoral head displacement and medial femoral strain were measured for intact femur controls, after fixation of a 2-part reverse oblique subtrochanteric fracture and finally a 3-part reverse oblique subtrochanteric fracture with a lateral wedge defect. The samples were then loaded at 750 N for 10(4) cycles with both devices uniaxially locked, followed by 10(4) cycles with both devices fully biaxially dynamized (unlocked). For the 2-part subtrochanteric fracture pattern, both devices exhibited similar inferior displacements of the femoral head (average 2.0 mm) and medial femoral strain (approximately 70% of intact). Increasing abductor forces decreased medial compressive strain but did not significantly affect head displacement. For the 3-part fracture model, the MSP demonstrated significantly less inferior displacement of the head (1.6 mm vs. 2.1 mm) and both devices demonstrated significantly decreased medial strain. After cycling, head displacement increased approximately 50% in both devices and medial strain increased slightly. After unlocking and cycling, the MSP group showed significant lateral displacement of the proximal fragment. The IMHS and MSP devices provide similar stability for fixation of 2-part and 3-part reverse oblique subtrochanteric fractures. In a biaxially dynamized, 3-part reverse oblique fracture, displacement of the proximal fragment can occur with the MSP.

The Medoff sliding plate has a dual side capability along both the femoral shaft and neck to increase theoretically interfragmentary compression and load-sharing in hip fractures. We studied intertrochanteric fracture fixation in cadaveric bone to determine whether this device has a mechanical advantage over a standard sliding hip screw. 2-part and 4-part fractures were created in 12 cadaver femurs. The fractures were fixated and sequentially destabilized; bone and plate strains and fragment displacements were determined during testing, as a function of applied physiological loads before and after short-term cycling. The Medoff sliding plate imposed a higher mean medial cortex strain than the sliding hip screw in all fracture models and at all loading levels, and the difference was statistically significant in the 2-part and in the unstable 4-part fracture models. The loading of the medial cortex region after cycling was approximately 50% higher in the Medoff samples than in the sliding hip screw samples. There were no significant differences in plate strains, fracture displacements or load to failure between the 2 devices. These observations favor the dual sliding principle as regards providing fracture compression and load-sharing, which may explain low failure rates in clinical series of unstable intertrochanteric fractures, treated with the Medoff sliding plate.

Thirty-two consecutive subtrochanteric fractures in 32 patients were stabilized using the Medoff sliding plate and were followed up prospectively for 1 year. Two patients died during the first postoperative year. Twenty-nine of the remaining 30 (97%) fractures united by 1-year followup. Two types of plate dynamization schema were used: uniaxial (17 patients) and biaxial (15 patients). With uniaxial dynamization, plate sliding averaged 12 mm along the femoral shaft without medialization of the femoral shaft. With biaxial dynamization along the femoral shaft and the neck, plate sliding averaged 11 mm and screw in barrel sliding averaged 9 mm; medialization of the femoral shaft ranged from 0% to 35% of the femoral shaft diameter. Three fractures treated with uniaxial dynamization had migration of the lag screw within the femoral head; all three fractures united without additional screw migration after secondary or staged biaxial plate dynamization.

In a prospective study, 94 consecutive patients with unstable intertrochanteric fractures were treated by 16 surgeons, using a modified 4-hole Medoff sliding plate and followed clinically and radiographically for 1 year. Weight bearing after surgery was allowed as tolerated. This new device is smaller and uses a simpler technique of insertion than the original 6-hole Medoff sliding plate. The modification of the plate makes biaxial sliding along both the shaft and the neck of the femur obligatory. All fractures united and no postoperative lag screw penetration occurred. The use of a shorter side-plate with 4 cortical bone screws was sufficient for fixation and no plate loosening or breakage was observed. On the basis of this experience, biaxial dynamization seems to facilitate fracture impaction and stability, and the simplified 4-hole Medoff sliding plate appears to be a suitable method for the treatment of unstable intertrochanteric fractures.

Objective: To evaluate the effects of dynamization of a sliding hip screw plate on the fixation stability for several types of subtrochanteric fractures. Clinical results of treating reverse oblique fractures occasionally show medialization of the femoral shaft., Design: Two types of plate dynamization were compared using the same test protocol in identically prepared groups of uniform, artificial femurs., Methods: Sawbones composite femurs (Pacific Research Labs, Vashon, WA) having five orientations of simulated subtrochanteric fractures were used with the Medoff plate (Medpac, Inc., Valencia, CA) either fully dynamized or with the sliding lag screw locked. These specimens were physiologically loaded and cycled and displacements of the proximal femur determined., Results: Significantly more shaft medialization occurred with reverse oblique fracture patterns when the Medoff plate was fully dynamized., Conclusion: Clinical treatment of reverse oblique fractures with the Medoff plate should be performed using the lag screw locked and only the plate dynamized.

Data influencing the outcome of rehabilitation after hip fracture were obtained from 103 consecutive patients. All were admitted from their own homes and were observed at the time of discharge from the hospital and at three weeks, four months, one year, five years, and ten years postfracture. Background and functional variables were recorded and analyzed by means of multivariate discriminant statistical techniques. The three most important variables for discharge to home were (1) the ability to walk two weeks after surgery, (2) living with someone, and (3) good general health. From four months until ten years postfracture, the most persistent positive variable for returning to and living at home was an active prefracture lifestyle. The most persistent negative variable was old age. By means of prognostic schemes, it is possible, as early as the time of fracture or a few days after surgery, to make a reliable prediction as to whether the patient will return home. Both the patient and society benefit from early rehabilitation at home in cooperation with primary care personnel and social workers, as it reduces the cost of the injury by avoiding a lengthy hospital stay and unnecessary institutional aftercare.

Function and social outcome for 103 consecutive patients, mean age 75 years, admitted from their own homes after a hip fracture were studied during a 10-year period. Within 4 months after the fracture, 81 patients had returned home, and the percentage of survivors living at home from then on was then fairly constant. At 10 years after fracture, 31 patients were living at home, 6 were in institutions, and 66 were dead. ADL, walking ability, and household activities remained at the level already achieved within 4 months after fracture during the 10-year period. The need for social services help did not increase; about one third of the survivors had communal home help throughout the 10-year period. Patients who before fracture were healthy and living with someone and within 2 weeks after the fracture could walk with a four-legged aid or better had a good prognosis for living in their own home. The hip fracture did not effect their subsequent fate.

A statistically significant increase in the incidence of fractures of the distal radius was found in the general population of southern Sweden during recent decades. As regards fractures of the proximal femur, an increase in the incidence of trochanteric fractures was observed only in women. In male patients at a mental hospital the fracture rate of the distal radius was the same as in the general population but the fracture rate of the proximal femur was about twelve times higher. In female patients at the same mental hospital the fracture rate of the distal radius was three times greater and that of proximal femur about seven times greater than that of the general population. This difference may not only be due to an increased skeletal fragility in patients in mental institutions but may also suggest poorer protective mechanisms against falls. Undiagnosed cardiovascular or neurological diseases, for example intermittent cardiac arrhythmia or transient cerebral ischaemic attacks, may cause falls. Early diagnosis and treatment of such diseases may reduce the number of fractures of the proximal femur.

From 1966 to 1982 new concepts in the treatment of fresh femoral neck fractures were introduced at a university hospital in Sweden. These included immediate postoperative weight-bearing, a program with rehabilitation at home in collaboration with primary care, and an alteration of the treatment policy from primary hemiarthroplasty to a flanged nail and finally to hook pins. The total annual number of hospital days was reduced by about one-third during this period in spite of the fact that the annual number of femoral neck fractures doubled. Thus, the mean hospitalization time decreased from 44 to 16 days. The proportion of patients admitted from their own homes decreased from 80% to 52% during the 17-year period, and for these, the return rate home at discharge from the hospital increased from 44% to 75%. According to several reports from Scandinavia, the number of hip fractures will double in the next two decades. Ways of further reducing the hospitalization time, new techniques, and, if possible, methods of preventing hip fractures must be sought.

From 1976 onwards an active rehabilitation programme has been applied to elderly patients with fresh hip fractures at the Department of Orthopaedics in Lund in Southern Sweden. This involves early mobilisation in the hospital (internal fixation and immediate weight-bearing) and at home, rehabilitation in cooperation with primary health care personnel from the time of the patient's admission. The purposes of this investigation were to evaluate the effect of this programme in primary care and to assess the consumption of resources for rehabilitation at home of patients with cervical or trochanteric hip fractures. One hundred of 161 consecutive patients returned home directly on discharge from the hospital and were followed up until four months after the fracture by the home care unit (a primary health care centre). Most patients regained their previous functions within four months of their fractures. Patients with cervical fractures consumed less resources for rehabilitation than patients with trochanteric fractures. The total cost per patient was ten times higher for care at a convalescent-home than for rehabilitation at home through primary care. Early at home rehabilitation of elderly patients with hip fractures gives good results at a minimal cost and is thus of advantage both to the patient and to the community.

A statistical investigation using multivariate techniques was made of the rehabilitation outcome of 103 consecutive elderly hip fracture patients, all admitted from their own homes. Cluster analysis revealed two main groups of variables, i.e., background variables (age, general medical condition, type of fracture, sex, living with someone) and functional variables (prefracture ability to visit someone and to shop, ability to walk and to manage activities of daily living two weeks postsurgery). A stepwise linear discriminant analysis was used, to estimate the probability of a given patient returning home. At discharge from hospital, certain factors, i.e., ability to walk two weeks postsurgery, living with someone, general medical condition, and type of fracture, were found to be most important for direct return home. At one year after hip fracture, the prefracture ability to visit someone and the age of the patient were of most prognostic significance for having returned and remained at home. The accuracy of the prediction tested by a "jackknife" procedure showed an over all increasingly correct classification during the follow-up year, more than 80% correct for all patients at discharge and 86% correct at one year. This approach to the analysis of soft data concerning hip fracture rehabilitation may prove of prognostic value also in sociomedical systems elsewhere.

Sixty-eight patients with hip fracture, mean age 79 years, from the city of Lund, were studied with special reference to functional and social rehabilitation at follow-up 1 year later. As compared with patients coming from institutions for permanent care, patients coming from their own homes had a significantly better prognosis in terms of survival, mobility and ability to cope with activities of daily living (ADL). However, patients returning home needed increased domestic help. Patients living with someone returned home sooner than those living alone. Although many of the patients who returned home could walk without support or with a walking-stick, more than one half did not go out shopping. More active measures, e.g. early home visits by a rehabilitation team, might give the patients more self-confidence and independence. Immediate weight-bearing did not appear to impair healing of the hip fracture or increase the risk of necrosis of the femoral head.

A program for early mobilization in the hospital and rehabilitation at home after hip fracture was developed in cooperation with local health and social authorities and applied to 103 consecutive patients having a mean age of 75 years. All were admitted to the hospital from their own homes. Three fourths of the patients returned home directly after postoperative mobilization periods of usually two to three weeks in hospital. Four months after the fracture 81 of 99 surviving patients were at home, most of them having regained their prefracture functional status. One year after the fracture 91 patients were alive, and 78 of these were at home with no functional loss, compared with their condition at four months. Some of the social and medical factors which may already be pertinent to the recovery outcome at the time of fracture are identified. Eight to nine of ten patients with two or three positive factors ("healthy," living with someone, and ability to walk two weeks postsurgery) returned directly home. This study suggests the importance of intensive support, in the form of information to patients and relatives, and close cooperation between hospital staff and community care authorities. By this means, a continuity of care and early permanent independence can be achieved for elderly hip fracture patients and institutionalized rehabilitation can be reduced with benefit for both the individual and society.

The rehabilitation outcome of seventy-eight consecutive patients with nailed hip fractures admitted to a hospital for chronic care from an orthopaedic department during 1977 through 1980 was followed for two years. They comprised only 13% of all hip fracture patients, the others being discharged to their own homes or old people's homes. Thirty-four of the admitted patients came originally from their own homes, 23 from old people's homes and the others from hospitals for chronic care. Each had been selected for long-term care by the orthopaedic surgeon and his staff as the likelihood of rehabilitation in his/her original habitat was considered poor. Because of an active rehabilitation at the hospital for chronic care, one-third of the surviving patients were discharged to their own homes or old people's homes within one year after the fracture. Most of these patients came originally from their own homes. Once discharged, the patients did not need to return to the hospital for chronic care.

The hip fracture incidence in the city of Lund and its rural surroundings was studied for the years 1966, 1972, 1981, and 1986. The total incidence increased from 3.3 to 5.1 per 1,000 inhabitants above 50 years of age. For persons more than 80 years old, the incidence almost doubled from 13.2 to 25.5, i.e., this group represented the entire increase in incidence. In the urban population, men with cervical fractures had an increased incidence. A smaller increase in incidence for both men and women was found in the rural area. Compared with larger cities, the incidence increase in the urban population in Lund was lower over time, but in 1986 the figures were comparable to those in Gothenburg in 1981. The total incidence in the mixed urban and rural population was as of 1981 higher than in Denmark and Finland, but lower than in Norway. If the incidence in the elderly continues to increase to 1995, there will be three times as many hip fractures as there were in 1966.

With the aid of Tc-MDP-scintimetry 1-2 weeks after nailing of femoral neck fractures, it is possible to distinguish fractures liable to complications. Due to the suspicion that frequent peroperative vascular damage was caused by the four-flanged nail (Rydell), a less traumatizing cylindric nail (Hansson) with an insertion instrument was used. In a prospective investigation in January 1981-February 1982, which included all intracapsular femoral neck fractures, the two above-mentioned methods of osteosynthesis were used randomly. Intravital staining with tetracycline showed the peroperative circulation equivalent in Rydell and Hansson groups. A significant difference in postoperative isotope uptake could be noted between the two groups in 37 patients with undisplaced fractures. In 34 of 45 displaced fractures in the Rydell group evidence of circulatory deficiency appeared in the postoperative scintimetry but in only 23 of 52 of the displaced fractures in the Hansson group, a statistically significant difference. The latter figure corresponds well to the incidence of peroperatively registered severe vascular injury evaluated by tetracycline labelling.

Lateral retinacular release by Z-plasty technique in selected patients provides a relatively simple procedure for relief of symptoms in patellar compression syndrome and is a satisfactory initial surgical procedure in cases not responding to conservative therapy. Unfortunately, there is no specific symptom complex, physical finding, radiographic finding, or arthrotomy finding which delineates the patient with patellar compression syndrome who will benefit from an isolated lateral retinacular release. Some patients may require further extensor mechanism realignment procedures (e.g., medial capsular reefing, tibial tubercle transplantation, tibial tubercle elevation, etc.) to relieve the aggravating symptoms of parapatellar and retropatellar pain.

A prospective study of the development of necrosis of the femoral head was performed in 34 patients with fractures of the femoral neck. Technetium-99m MDP images of the hip regions were obtained immediately after nailing of the hip and at four, eight and 12 months. There was a good correlation between qualitative and numeric evaluation of isotope uptake in the femoral heads. Comparison of the activity level in the femoral head on the fracture side with that in the contralateral control site showed activity ratios to vary between < 1.0 for those heads showing a general reduction in activity on conventional images to > 1.4 with a mean of 2.0 for those showing increased activity. The initial postoperative images in 2/7 undislocated fractures showed a marked depression in femoral head activity on the fracture side; 13/21 dislocated fractures showed a similar defect suggesting a significant loss of bone remodeling. Normal Tc-99m activity in the femoral head (category 2) was observed in two fracture cases imaged within 24 hours of fracture, just prior to nailing. Repeat studies within one week of fracture and nailing demonstrated a marked depression in activity (category 0). Radiographic evidence of collapse later developed in both patients. The perfusion and blood pool images were useful for identifying femoral heads with deficient circulation. This investigation has demonstrated that the nailing procedure may threaten the vascular condition of the femoral head in hip fracture, that a dead head may be radiographically normal and clinically asymptomatic, and that the metabolic condition of the femoral head may be expressed in numeric terms suitable for statistical analysis.

Two series of elderly patients with hip fracture were compared with regard to hospitalization time and social situation after discharge from hospital. Our series included 131 patients from 1966 with late weight-bearing and 362 patients from 1972--1973, mobilized with early weight-bearing. Approximately two-thirds of the patients came from their own homes and one-third from institutions. The mean hospital stay for patients discharged to their own homes was 7 weeks in 1966 and 3--4 weeks in 1972--1973. This decrease in hospitalization time did not cause any increase in the proportion of patients discharged to institutions. Thus, among patients admitted from their own homes 48 per cent of the survivors returned directly home in 1966, and 62 per cent in 1972--1973. As compared to the prefracture mobility, postoperative mobility at 2 weeks proved to be a better indicator of the patient's chances of returing home. This may be a helpful guide when planning the aftercare of these patients.