Although bone mass is a contributory risk factor for hip fracture, its distribution about the femoral neck is also important. Femoral neck biopsies were obtained from 13 females with intracapsular hip fracture (fracture: mean age 74.3 ± 2.3 years [SEM]) and 19 cadaveric samples (control: 9 males and 10 females 79.4 ± 1.7 years) and the areas of cortical and cancellous bone were quantitated in octants. In the control group, although males had larger bones than females, the proportions of cortical and cancellous bone were not different (p > 0.05) between the genders. The total amount of bone, as a proportion of bone + marrow, was significantly reduced in the fractures compared with the female controls (%Tt.Ar: fracture 27.83 ± 1.18, female control 33.62 ± 1.47; p = 0.0054). Reductions in cortical bone area occurred in all regions but particularly in the inferior, inferoanterior, and anterior octants (p < 0.05). There were no differences between cases and controls in the regional amount of cancellous bone (all regions, p > 0.178). Marked reductions in mean cortical bone width between the fracture and female control group occurred in the anterior, inferoanterior (31%), and superoposterior (25%) regions. Representing cortical widths as simple Fourier functions of the angle about the center of area (R 2 adj = 0.79) showed in the cases that there was preservation of the cortical bone in the inferior region, with the proportional loss of cortical bone being greatest in the inferoanterior and superoposterior regions. It is concluded that loss of cortical, rather than cancellous, bone predominates in cases of femoral neck fracture. This loss occurs primarily along the inferoanterior to superoposterior axis. As this axis bears the greatest strain during a fall, it is hypothesized that specific thinning of the cortex in these regions leads to an exaggerated propensity to fracture in those so affected, above that resulting from an equivalent general decrease in bone mass. (J Bone Miner Res 1999;14:111-119)
We report a long-term follow-up of abduction-extension osteotomy of the first metacarpal, performed for painful trapeziometacarpal osteoarthritis. Of a consecutive series of 50 operations, 41 thumbs (82%) were reviewed at a mean follow-up of 6.8 years. Good or excellent pain relief was achieved in 80%, and 93% considered that surgery had improved hand function, while 82% had normal grip and pinch strength, with restoration of thumb abduction. Trapeziometacarpal osteoarthritis is associated with degeneration of the palmar beak ligament 10 and articular degeneration starts on the joint surfaces adjacent to it. The cartilage of the dorsoradial joint surface is spared until late in the disease process. 10 A recent cadaver study has shown that extension osteotomy of the first metacarpal shifts the area of joint contact from the worn palmar cartilage to the normal dorsal surface. 11 We describe our experience of osteotomy in a large series of patients over a period of 12 years. Patients and MethodsWe carried out 50 operations in 42 patients; 41 thumbs (82%) in 33 patients were available for review at a mean of 6.8 years (2 to 12) from operation. The average age at operation was 57 years (20 to 73). Nine of the operations were in men and 32 in women, and the dominant hand was involved in 20 patients. Nine patients were lost to followup. Three had died, one had moved and could not be contacted, and three very elderly patients could not be traced. Another elderly man was too confused to co-operate. One patient was contacted by telephone but did not wish to be reviewed. When last seen she had complete relief of pain, full abduction and a strong grip. The patients were reviewed by a surgeon who had not been involved in the operation. Pain and hand function were assessed by the patient, using a self-administered questionnaire. Grip strength was measured with a Jamar dynamometer (Asimov Engineering Company, Los Angeles, California), and pulp to pulp (pinch) and lateral pinch (key-grip) with a B & L hydraulic pinch meter (B&L Engineering, Santa Fe Springs, California). The mean of three readings was compared with normal ranges matched for age and sex. 12 The range of movement and maximum abduction were measured clinically with a goniometer. Thumb opposition and the ability to flatten the palm were assessed and recorded. Indications for operation. Surgery was carried out when pain which interfered with everyday activities had not responded to conservative treatment with a splint, nonsteroidal anti-inflammatory drugs or injection with lignocaine and hydrocortisone. Osteotomy was only considered for mild and moderate degenerative changes confined to the trapeziometacarpal joint, scaphotrapezial wear being a contraindication. The preoperative radiographs were graded as described by Eaton and Littler 13 : grade 1, no radiological changes; grade 2, osteophytes or intra-articular fragments of <2 mm with no narrowing of
A group of 12 women with traumatic fat swellings around the buttock region is presented.2. The structure of the subcutaneous tissue and the mechanism in formation of the lipomata are described.3. Treatment of the essentially cosmetic deformity is discussed and excision of the lipomatous mass is advised when symptoms indicate this.
The results of treatment using the Herbert screw in 50 consecutive patients with delayed or established non-union of the scaphoid are reported. 14% of these fractures failed to unite after operation and a further 20% required prolonged protection, uniting within six months. There were significant technical problems in 28% of operations. A bone graft was only used when there was significant collapse of the scaphoid (52%) and the cases without graft did just as well. Overall, the results do not support the view that this method of treatment is a significant advance over Russe grafting in terms of union rates, but confirm that it produces similar results without the need for prolonged immobilisation and without the need for bone grafting in almost half the cases, although there can be significant technical problems with the procedure.
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