We randomised prospectively 44 patients with fractures of the shaft of the humerus to open reduction and internal fixation by either an intramedullary nail (IMN) or a dynamic compression plate (DCP). Patients were followed up for a minimum of six months. There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons' score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. There was a single case of shoulder impingement in the DCP group and six in the IMN group. Of these six, five occurred after antegrade insertion of an IMN. In the DCP group three patients developed complications, compared with 13 in the IMN group. We had to perform secondary surgery on seven patients in the IMN group, but on only one in the DCP group (p = 0.016).Our findings suggest that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.

Computed tomography measurement is a repeatable method of assessing tibial torsion and in this study revealed a significantly higher incidence of rotational malreduction than that previously reported in the literature.

Summary Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0.83, 95% CI 0.63–1.09; p=0.18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1.91, 1.06–3.44; p=0.0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0.82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0.41) and sepsis (seven [1%] vs six [1%]; p=0.79). Interpretation In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. Funding National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians’ Services Incorporated.

Purpose The aim of the study was to assess the use of the centre-edge (CE) angle in the assessment of pincer femoroacetabular impingement (FAI) for reliability and predictability in the diagnosis. Methods Between 2004 and 2008, 55 patients underwent surgical treatment for FAI. A control group of 30 was identified among patients attending the emergency department with normal radiographs. Radiographs were assessed by two independent observers both before and after the operation. Nine patients with trauma were excluded. The magnetic resonance arthrogram reports of the remaining 46 patients were assessed for pincer FAI. Nineteen patients were identified and underwent repeat radiographic assessment. All underwent surgical dislocation of hip (SDH), acetabular, with/without femoral osteochondroplasty. Acetabular depth and version were also assessed. The intraclass correlation (ICC) was used to assess reliability of the CE angle. The paired t test and independent groups t test were used to assess the difference between the pincer FAI group, both pre-op and post-op and against controls. Results The control and pincer groups were similar in demographics (p=0.1769). Coxa profunda was present in 14 patients with eight also having retroverted acetabuli. Of the rest two had retroverted acetabuli and one protrusio. The mean CE angle in the control group was 31.4°, in the pre-op pincer group 46.2°and in the post-op pincer group 38.3°. The ICC for intra-observer correlation was 0.977 and 0.992 pre-op and 0.986 and 0.974 post-op. The ICC for inter-observer correlation was 0.960 and 0.957 pre-op and 0.979 and 0.967 post-op.The p value was <0.001 between the controls, the pre-op and post-op pincer groups. The test characteristics using the CE angle ≥ 40 is a reasonably good predictor of FAI, with a sensitivity of 84.2% and a specificity of 100%. Conclusions The pincer FAI can be reliably assessed with the CE angle and can be predicted in patients presenting with FAI.