The fate of the articular cartilage in intracapsular fracture of the femoral neck (articular cartilage in femoral neck fracture)

The fate of the articular cartilage of the hip joint with intracapsular neck fracture was studied by histological, histochemical and autoradiographic techniques and by using a polarized microscope and a scanning electron microscope. Cartilage specimens from 93 femoral heads and 7 acetabula were obtained from fractured hips 2 days to 4 1/3 years postfracture and from control hips with various disorders. The cartilage degeneration appeared 2 weeks after fracture and advanced steadily with time. The matrix was covered, invaded and ultimately replaced by the fibrous tissue. Chondrocyte viability, though it was lost from the surface, was recognized in the deep matrix even in the oldest fracture examined. It is concluded that the humoral factor directly caused by the injury as well as the biomechanical impairment, i.e. a loss of physical stress, may play an essential role in the pathogenesis of the degeneration. The possibility of regeneration was discussed.     

Intracapsular hip pressure after femoral neck fracture

A consecutive series of 34 patients with femoral neck fractures was included in a prospective study aimed at evaluating preoperative variations in intracapsular pressure after changes in hip position, hip traction, and aspiration of hemarthrosis and their influence on the development of femoral head necrosis. Patients were observed for 7 years after surgery. Before aspiration, the mean intracapsular pressure in the antalgic physiologic position was 44.4 mm Hg. There were no differences between displaced and undisplaced fractures. The pressure was a maximum (mean value, 124.8 mm Hg) with the hip in extension and inward rotation, this pressure being greater than the blood systolic pressure in most cases. Hip traction of 3 kg in the antalgic physiologic position was found to be highly effective in preventing any bone flow tamponade effect in displaced and undisplaced femoral neck fractures: the mean intracapsular pressure decreased to 28.5 mm Hg. Aspiration of the hemarthrosis induced a significant decrease in intracapsular pressure only in cases with impaired vascularity of the femoral head as measured by scintigraphy using 99mTc labeled methyldiphosphonate. Aspiration of the hemarthrosis therefore is indicated only in the above cases, although it is less effective than hip traction in the antalgic position. There was no significant correlation between intracapsular pressure and the scintigraphy ratio. Avascular necrosis of the femoral head was detected in six cases. Among these, five patients had an intracapsular pressure below their diastolic blood pressure. This could indicate that vascular damage related to the fracture could be an important cause of bone necrosis despite that blood supply can be decreased by a tamponade effect.     

Modular unipolar versus bipolar prosthesis: a prospective evaluation of functional outcome after femoral neck fracture

Between January 1, 1987, and December 31, 1992, 140 community-dwelling geriatric patients > or = 65 years of age with a displaced femoral neck fracture (Garden III-IV) underwent primary prosthetic replacement and were followed prospectively for a minimum of 1 year. Overall, 92 patients received a cemented bipolar prosthesis and 48 patients received a cemented modular unipolar prosthesis. There were no statistically significant differences between the two groups with respect to preinjury characteristics (age, sex, and number and severity of medical comorbidities) and functional ability. There were no statistically significant differences between the two groups with regard to the number of postoperative complications, length of stay, and 1 year mortality rate. An in-depth functional evaluation was obtained as follows: level of ambulation, independence in basic activities of daily living (feeding, bathing, dressing, toileting), and independence in instrumental activities of daily living (food shopping, food preparation, banking, laundry, housework, and use of public transportation). At 1 year follow-up, no statistically significant differences in functional ability were identified between the unipolar and bipolar groups. Furthermore, at a minimum of 1 year follow-up, there were no statistically significant differences between the two groups with regard to the need for revision surgery or the incidence hip pain. Based on the results of this study, there does not appear to be any advantage to the use of bipolar endoprosthesis for the treatment of femoral neck fractures in the elderly patient. The lower cost of modular unipolar prostheses compared with bipolar prostheses provides additional support for their use.     

Port-site metastases. A prospective study of 131 cases

Laparoscopic staging and laparoscopic treatment of gastrointestinal malignancy is still controversial because some studies report port-site metastases. BACKGROUND: The aim of the study is to determine in 131 patients, with prospective follow-up, after laparoscopic staging or laparoscopic treatment the incidence of port-site metastases. METHODS: 131 patients, with gastro intestinal malignancy, proved or with peritoneal carcinomatis or liver metastases, were included. In 57 cases only laparoscopic staging is performed in 49 cases laparotomic treatment is performed a after laparoscopic staging; in 57 cases (43.5 per cent) tumor invaded serosa. RESULTS: The median follow-up was 17.7 months (3 to 62 months). 502 port-sites were controlled. One patient (0.7%) has presented one port site metastasis 3 months after right colectomy for carcinoma with local carcinomatis. CONCLUSION: The study affirm that port-site metastases are rare. They are favorised by serosa invasion. The low rate indulge in laparoscopic staging to recognize occults lesions which are not detected by conventionals examinations in 44.2 per cent in this study.     

Primary endoprosthetic replacement for acute femoral neck fractures. A review of 150 cases

A review of 150 consecutive endoprosthetic replacements for acute displaced femoral neck fractures was undertaken to investigate the following serious criticisms of the method. The first is excessive hospital mortality and morbidity, especially in comparison to internal fixation procedures retaining the femoral head. The second is pain, derived from the "unphysiologic" nature of placing a metal prosthesis against otherwise normal acetabular cartilage. In the first instance the procedure is condemned as too major an operative procedure, poorly tolerated by elderly patients. In the second, it is a poor procedure if it requires revision in a patient incapable of withstanding more than one operation. A detailed follow-up shows that the in-hospital mortality in patients averaging 79.8 years of age, was 4%, lower than published mortality for either hemiarthroplasty or internal fixation. Close postoperative monitoring, antibiotic and antiembolic prophylaxis (2.0% infection, 6% embolic complications), and rapid mobilization contributed significantly to the increased survival. Painful endoprostheses, the most frequent complication, occurred in 16.7% of the 125 patients available for follow up at an average of 21 months. The causes of pain were considered technical problems judging prosthetic neck length, head size, sinking and loosening. Dissolution of the medial femoral neck was associated with a narrow stem prosthesis in five of six of these failures. The above statistics suggest that primary endoprosthetic replacement for displaced femoral neck fractures carries with it neither the excessive mortality and morbidity nor the pain induced potential for early reoperations that have been suggested by the recent literature.     

Balanitis and infectious agents. A prospective study of 100 cases

INTRODUCTION: The aim of this study was: 1) to evaluate the rate of micro-organism isolation in 100 patients consulting for balanitis at the Centre of sexually transmitted diseases at the St. Louis Hospital in Paris in comparison with that of micro-organisms isolated in 60 men without balanitis; 2) to search for a possible correlation between the clinical aspect of the disease and the nature of the infectious agent identified. METHODS: One hundred consecutive patients were included in the study. All underwent a clinical examination and samples were taken for bacteriology, mycology and virology examinations. Sixty healthy volunteers served as controls. Two samples were taken from the balanopreputial groove in search for fungi and bacteria. RESULTS: Candida albicans (CA) was isolated in 33 p. 100 of the patients. A pathogenic bacteria (beta-haemolytic streptococci, Staphylococcus aureus, Klebsiella), or a potentially pathogenic germ (Haemophilus parainfluenzae, anaerobic bacteria, Gardnerella vaginalis, Streptococcus milleri, group HB5) was found without CA in 28 p. 100 of the cases, a commensal flora (enterobacteria, group D streptococci) was found without CA in 8 p. 100 and in 31 p. 100 of the cases non causal agent could be identified. DISCUSSION: This series confirms the non-pathogenic nature of commensal bacteria: the number of isolations was similar in the subjects with and without balanitis (p < 0.9). The role played by the other bacteria in the development of balanitis is discussed: saprophytic association or direct pathogenesis? The significant difference in the rate of bacteria isolations in patients with balanitis compared with controls (p < 0.001) is in favour of a pathogenic role. The clinical presentation was not predictive of the presence of any particular micro-organism excepting the presence of pustules which were highly suggestive of candidiasis.     

Implant/bone constructs in femoral neck osteotomy. An autopsy study

Previous studies have suggested that three rather than two screws may give better results in the treatment of femoral neck fractures. In the present study, the strength of various screw/bone constructs in femoral neck osteotomy was analyzed. Transverse osteotomies on 65 cadaver femora were fixed with two or three screws of two types: one with a shank diameter of 6 mm and thread diameter of 8 mm, and a prototype screw with equal shank and thread diameter of 7 mm. The femoral heads were subjected to static and cyclic loads in the one-legged stance position. Single-energy quantitative computed tomography measurements were correlated to load. The two experimental models resulted in different patterns of failure of the bone/implant constructs, otherwise the results were similar. Three of the prototype screws gave the strongest construct, while two of the other screw type were stronger than three. The explanations for the diverging properties of the different bone/implant constructs may be that large threads destroy too much of the bone trabeculae, and that screw threads larger than the shank may destroy the drill canal and produce an unstable situation compared with screws with equal shank and thread diameter.     

Cortical aging differences and fracture implications for the human femoral neck

Clinical imaging techniques cannot consistently identify individuals at risk for hip fracture. Individual differences in falling likelihood partly account for these inconsistencies, but it is also thought that microscopic bone changes may play a role. In this study, subcapital, mid-neck, and trochanteric sites from eight young adult (26 +/- 7 years) and nine older (63 +/- 3 years) males were studied using backscattered electron imaging to identify age-related microscopic structural and mineral changes around the cortex. Cortical bone volume (BV(Ct)/TV), cortical void volume (Vd.V(Ct)/TV), hypermineralized bone volume (BV(H-min)/TV), the number of osteons/mm2 (N.On/B.Ar), lacunae/mm2 (N.Lc/B.Ar(Ct)) in the cortex, lacunae/mm2 (N.Lc/B.Ar(H-min)) in the hypermineralized phase, and cortical thickness (Ct.Th) were measured at subcapital, mid-neck, and trochanteric levels. Cortical void volume showed no differences (P = 0.26) between levels in the younger group, but differences (P < 0.05) were observed in the older group, indicating locational osteopenic differences. Cortical thickness differences were greater at the subcapital (27.7%) and mid-neck (25.2%) levels than at the trochanteric level (10.5%). Both age (P = 0.0022) and level-location interaction (P < 0.0001) influenced the hypermineralized bone volume present, with larger hypermineralized regions generally occurring at the thinner superior locations. Significant (P < 0.05) lacunar differences with aging in the hypermineralized phase suggest a necrotic origin. Artifactual cracks occurred preferentially within the hypermineralized phase, indicating localized reductions in fracture toughness, which may provide a site for crack initiation following an impact.     

The unreamed AO femoral intramedullary nail, advantages and disadvantages of a new modular interlocking system. A prospective study of 67 cases

The aim of this study was to investigate associations between sudden infant death syndrome (SIDS) and social factors in the Nordic countries. A case-control study was conducted in Denmark, Norway and Sweden: The Nordic Epidemiological SIDS Study. Parents of 244 SIDS infants and 869 control infants matched on gender, age at death and place of birth filled in questionnaires. The dataset was analysed by conditional logistic regression. In univariate analysis, the following sociodemographic factors were associated with an increased risk of SIDS: low maternal age [odds ratio (OR) 7.8; 2.8-21.5], high birth order (OR 4.4; 2.5-7.5), single motherhood (OR 2.9; 1.7-5.0), low maternal education (OR 4.5; 2.8-7.1), low paternal education (OR 3.0; 1.9-4.7), maternal unemployment (OR 2.4; 1.8-3.4) and paternal unemployment (OR 4.0; 2.7-5.9). In a multivariate analysis where maternal smoking was also included, only paternal unemployment, young maternal age and high birth order remained significantly associated with SIDS. Housing conditions were not associated with SIDS. However, the risk of SIDS was high if the family had lived in their present home for only a few years (OR 2.3; 1.3-4.1). Sociodemographic differences remain a major concern in SIDS in a low-incidence situation and even in an affluent population with adequate health services.     

Postoperative arrhythmias in open-heart surgery, A study on fifty cases

50 consecutive patients undergone open heart surgery were analyzed regarding postoperative arrhythmias in the first postoperative 3 days. Disturbances of rhythm occurred in each case of our group, serious or not serious (100%). Ventricular premature beats were the most frequent type of arrhythmia in the first and second postoperative days (80%). Two cases expired postoperatively. In one of them complete atrioventricular block developed after double valvular replacements (mitral and tricuspid). The other died of low cardiac output syndrome. Etiology of the arrhythmias after open heart surgery is not clear in the absence of electrolyte and metabolic disturbances, digitalis intoxication and surgical trauma to the conduction system and coronary arteries. Low cardiac output syndrome, hypotension and hypoxia can also be blamed in the formation of these arrhythmias. Other factors such as the prolongation of anoxic arrest, irritation of the ventricular septum by valvular prostheses, cardiac irritation by thoracic tubes, psychologic trauma, halothane anesthesia and coronary arterial disease in the old age group may be the possible predisposing factors in these patients.     

Pain due to bone insufficiency as a symptom heralding femoral neck fracture

Obstructive jaundice is associated with a predisposition to systemic hypotension and acute renal failure. Altered vascular reactivity may contribute to the development of hypotension. In this experimental study on dogs, alterations in vascular contractile responses to noradrenaline, serotonin and KCl were investigated. Contractile responses to noradrenaline, serotonin,,, KCL and relaxation responses to papaverin and acetylcholine were provoked in isolated femoral arteries of both control dogs and animals with obstructive jaundice. In this situation concentration-response curves of noradrenaline and serotonin were blunted when compared with controls. This blunting disappeared when endothelium was removed. In rings precontracted with phenylephrine, EDRF relaxation responses to acetylcholine were increased significantly as compared to controls: at lower concentrations maximal relaxation response occurred. Contractile responses to KCl and relaxation responses to papaverin did not differ between the groups, endothelium present or removed. These results indicate that obstructive jaundice induces a decrease in vascular contractile responses and an increased EDRF relaxation response. We suggest that an excess in the amount of released EDRF may be one of the causes inducing systemic hypotension in obstructive jaundice.     

Chrysotherapy. A prospective study

A 4-year prospective clinical study of chrysotherapy was designed to reexamine old beliefs and traditions, and to test potentially new approaches to chrysotherapy. The standard weekly dosage of 50 mg was compared to that based on 1 mg/kg body weight; no significant differences were found. The rapidly absorbed aqueous thiomalate was compared to the slowly absorbed oil repository thioglucose; the latter produced significantly less side effects and an appreciably higher percentage of improvement. Almost half (43%) of nonresponders on standard regimen had a satisfactory clinical response at higher dosage levels without increase in toxicity. Some of these findings vary so much with traditional beliefs and practices that the authors urge caution in their interpretation. But generally speaking these problems are technical and do not detract from the conviction that chrysotherapy is valuable and comparatively safe in the management of rheumatoid arthritis and that it deserves more widespread application in clinical practice.     

Deformities of the spine in neurofibromatosis. Clinical and radiographic study of 46 cases

Scoliosis, in particular kyphoscoliosis, is the most frequent bony abnormality in neurofibromatosis (up to 43 per cent). The most usually accepted aetiopathogenesis is a primary mesoblastic defect of the vertebrae, though other hypotheses exist. Hereditary factors have been shown to be present in about half the cases and the spinal deformity is almost always associated with skin changes, and less frequently with nerve or cardiac changes or with elefantiasis. The ages most affected are from four to eleven years, the commonest site is the dorsal spine and the average number of affected vertebrae is 5.5. There are three main radiological characteristics: widening of the spinal canal, widening of the intervertebral foraminae, and a scalloped appearance of the posterior borders of the vertebral bodies. From the point of view of prognisis the scoliosis is markedly progressive and difficult to control, even after bone maturity. In consequence, neurological symptoms frequently arise, usually as late complications.     

Causal assessment of drug-induced acute colitis. A prospective study of 58 consecutive cases

AIMS: The causal effect of drugs is underestimated in patients with inflammatory bowel disease. The aim of this study was to assess the causal implication of drugs in acute colitis. METHODS: A prospective study was conducted in 58 consecutive patients with an acute inflammation of the colonic mucosa. Recent drug intake was recorded and possible causal effects were analyzed exhaustively with respect to both intrinsic and bibliographic criteria. RESULTS: Causal assessment scores were high for 57 drugs and 41 patients. Drug-induced acute colitis was diagnosed in 35 cases. In 7 patients, physician practice had not taken into account drug use despite probable drug involvement. The main drugs implicated were antibiotics (n = 42) and non steroidal anti-inflammatory drugs (n = 10). CONCLUSION: Acute colitis is mainly induced by drugs.     

Validation of World Health Organization guidelines for pain relief in head and neck cancer. A prospective study

In a prospective study of 167 patients with head and neck cancer, we assessed the causes and mechanisms of pain, as well as the efficacy and side effects of analgesic treatment, along World Health Organization (WHO) guidelines. The majority of patients had pain caused by cancer (83%) and/or treatment (28%), 4% had pain due to debility, and 7% had pain unrelated to cancer. Palliative antineoplastic treatment was performed in 32% of patients. Systemic analgesics were administered on 97% of a total of 8,106 treatment days, and coanalgesics or adjuvant drugs on 100%. The treatment proved to be very successful, as severe pain was experienced only during 5% of the observation period. In the absence of serious side effects, the most frequent symptoms observed were insomnia, dysphagia, anorexia, constipation, and nausea. The use of analgesic and adjuvant drugs along WHO guidelines to treat pain in head and neck cancer is highly effective and relatively safe.     

A clinical and pathological study of 46 cases of sudden and unexpected death

A series of 46 autopsied adult cases of sudden and unexpected natural death were investigated. In this study, sudden and unexpected death was defined as any death occurring with 24 hours of onset of symptoms in a person with or without probable cause of death suggested by medical history. The cases included 31 males and 15 females aged 26 to 85 years (mean 66.6 years). Age distribution peaked in seventies. The lesions causing sudden and unexpected death according to the most frequent organ systems were, diseases of the heart (acute myocardial infarction with or without old infarct, 20; old myocardial infarction without acute infarction, 2; dilated cardiomyopathy, 2; sarcoidosis, 1; amyloidosis, 2; and valvular disease, 2), the aorta (ruptured aneurysm, 6; dissecting aneurysm, 2), the respiratory tract (pulmonary embolism, 7; pulmonary hypertension, 1), the alimentary tract (intestinal obstruction, 1), and other diseases (cause unknown, 1). The cardiovascular lesions were found in 78.2% of cases autopsied. The sudden and unexpected death caused by acute myocardial infarction was found in 47.8%, and acute myocardial infarction seemed to play a major role in cardiac sudden death in these series. The respiratory lesions were found in 17.4%. Four of seven cases with pulmonary embolism died in two weeks after surgical operation. The most common underlying disease was post-operative condition.