Graeme Holt

Or physiotherapy appointments, he removed his splint immediately on discharge, and he admits to moving the finger freely without restrictions, against advice. On examination it is evident that the patient has sustained a rupture of the tendon repair. Does the history of noncompliance with initial treatment affect decisions regarding the further management of this patient? The term compliance relates to the degree of constancy and accuracy with which an individual patient follows a prescribed treatment. Patient noncompliance is a common problem across all specialties and presents a major obstacle to safe, effective, and efficient health-care delivery. In this article, we discuss the risk factors for noncompliance, the difficult ethical and medico-legal dilemmas posed by this issue, and mechanisms for potential solutions to this common problem....

Background: Hip fracture is a common cause of morbidity and mortality in the elderly. As the risk factors for hip fracture often persist after the original injury, patients remain at risk for sequential fractures. Our aim was to report the incidence, epidemiology, and outcome of sequential hip fracture in the elderly. Methods: Data were collected during the acute hospital stay and at 120 days after admission from twenty-two acute orthopaedic units across Scotland between January 1998 and December 2005. These data were analyzed according to two separate time periods: by six-month intervals up to eight years after the primary fracture and by twenty-day intervals for the first two years after the primary fracture. Results: The risk of sequential fracture was highest in the first twelve months, affecting 3% of surviving patients and decreasing to 2% per survival year thereafter. Survival to twelve months after sequential fracture was 63% compared with 68% for those with a single fracture (p = 0.03). Sequential hip fracture was also associated with greater loss of independent mobility and changes in residential status compared with single fractures. Conclusions: Sequential hip fracture is a relatively rare injury. Individuals who sustain this injury combination have poorer outcomes both in terms of survival and functional status. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Despite improvements in implant technology and surgical technique, failure of total hip arthroplasty (THA) remains a persistent problem. This article reports clinical outcomes at a mean follow-up of 42 months using the Restoration cone/conical modular femoral revision stem (Stryker, Newbury, United Kingdom). A prospective cohort study was performed of 46 consecutive patients who underwent revision THA between January 2004 and June 2007. Patients were reviewed pre- and postoperatively at regular intervals for clinical and radiological assessment. Forty-six patients (17 men, 29 women) with a mean age of 72 years (range, 44–93 years) were observed for a mean of 42 months (range, 28–66 months). Indications for surgery included aseptic loosening/osteolysis (38/46 [83%]), periprosthetic fracture (4/46 [9%]), and infection (4/46 [8%]). Median time from index procedure was 16 years (range, 1–26 years). No patient was lost to follow-up. Two patients (4%) with well-fixed asymptomatic stems died during follow-up. Three patients (7%) sustained an early postoperative dislocation. One patient sustained a periprosthetic fracture after a fall. This was treated by osteosynthesis, and stem revision was not required. Mean Oxford Hip Score improved from 42 points (range, 24–57 points) to 28 points (range, 18–51 points) at 3-month follow-up ( P =.003). Median stem subsidence was 1.0 mm (standard error of the mean, ±1.7 mm; range, 0–7mm) at last follow-up. No patient developed loosening or osteolysis around the stem. The Restoration femoral revision system has favorable clinical and radiological outcomes at a mean follow-up of 42 months.

Advances in surgical technique and implant technology have improved the ten-year survival after primary total hip arthroplasty (THA). Despite this, the number of revision procedures has been increasing in recent years, a trend which is predicted to continue into the future. Revision THA is a technically demanding procedure often complicated by a loss of host bone stock which may be compounded by the need to remove primary implants. Both cemented and uncemented implant designs are commonly used in the United Kingdom for primary and revision THA and much controversy still exists as to the ideal method of stem fixation. In this article we discuss revision of the femur using cemented components during revision THA. We focus on three clinical scenarios including femoral cement-in-cement revision where the primary femoral cement-bone interface remains well fixed, femoral cement-in-cement revision for peri-prosthetic femoral fractures, and femoral impaction grafting. We discuss the clinical indications, surgical techniques and clinical outcomes for each of these procedures.

In this study we assess the clinical and radiological outcomes after surgical fixation of unstable, extracapsular fractures of the proximal femur using two designs of short intramedullary nail. We reviewed 158 patients of which 131 had fixation using the Intra Medullary Hip Screw (IMHS original Richards Compression Hip Screw design) and 27 with the original design Proximal Femoral Nail (PFN Synthes). Outcome measures including non-union, peri-implant fracture, post-operative function and mortality were similar between groups. Proximal screw cut-out and consequently re-operation rate were significantly higher for the PFN. A number of variables may predispose a patient to develop screw cut-out including gender, experience of surgeon, fracture pattern, implant design and tip-apex distance. As such a multivariable logistic regression model was used to investigate the independent effects of these variables on proximal screw cut-out. Only tip-apex distance was found to have a significant association with proximal screw cut-out and differences between implant designs could be accounted for by surgical technique rather than implant design. The results of this study suggest that both implants have similar post-operative outcome measures and complication rates when implanted correctly.

We have investigated how medical postponement, the time to surgery and the correction of medical abnormalities, according to McLaughlin criteria, before operation affected peri-operative mortality after fracture of the hip. From February to December 2007, in addition to core data, the Scottish Hip Fracture Audit collected information relating to surgical delay. Data were available for 4284 patients which allowed 30-day survival analysis to be performed. Multivariable logistic regression models were used to control for differences in case-mix. Patients with major clinical abnormalities were more likely to have a postponement and had a lower unadjusted 30-day survival. The time to operation and postponement were not associated with higher mortality after adjustment for case-mix. Correction of major clinical abnormalities before surgery improved the adjusted survival, but this improvement was not significant (p = 0.10). Postponement without correction of a medical abnormality before surgery was associated with a significantly lower (p = 0.006) 30-day adjusted survival. The possible benefits of postponement need to be weighed against prolonged discomfort for the patient and the possibility of the development of other complications.

Although statins are widely prescribed as cholesterol‐lowering drugs, a number of studies suggest that these compounds may have anabolic effects on bone. Our aim was to assess whether simvastatin affects the rate of fracture healing in humans. A prospective, double‐blind, randomized controlled trial was performed. Individuals who had sustained an undisplaced, extra‐articular fracture of the distal radial metaphysis were recruited from a trauma clinic. Patients were randomized to receive simvastatin 20 mg once daily or a placebo. Regular clinical and radiological follow‐up was undertaken for a 12 week period. Dual‐energy X‐ray absorptiometry assessment of bone mineral density was conducted at 2 and 12 weeks postinjury. Biochemical markers of bone turnover were assayed during the study period. Time to fracture union was defined as the time to cortical bridging in four cortices on plain radiographs. In addition, the rate of trabecular union was assessed. Eighty patients were recruited, of which 62 completed the study (31 in each group). Study cohorts were matched for age and gender. For patients receiving simvastatin therapy, the mean time to fracture union was 71.6 days (SD 22.2 days, SEM 3.8 days). This compared to 71.3 days (SD 21.3, SEM 4.1 days) for the control cohort (p = 0.6481). There was no significant difference between bone mineral density or bone biochemical markers between groups (p > 0.05). Despite promising results from in vivo and in vitro animal studies, simvastatin at a treatment dose of 20 mg once daily does not affect the rate of fracture healing in humans. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:281–285, 2009

While medical ethics is a complex topic, it is fundamentally a code of professional conduct, commonly based on the four principles described by Beauchamp and Childress¹¹. These principles are nonmaleficence, beneficence, autonomy, and justice.