Journal of Bone and Joint Surgery - British Volume Aspects of Current Management

[Aspects of Current Management] Early management of proximal humeral fractures with hemiarthroplasty: A SYSTEMATIC REVIEW

Kontakis, G., Koutras, C., Tosounidis, T., Giannoudis, P. — 2008-10-31

We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations.

Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7° (10° to 180°) and the mean abduction to 92.4° (15° to 170°). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted.

[Aspects of Current Management] A revolution in the management of fractures of the distal radius?

Downing, N. D., Karantana, A. — 2008-09-30

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.

[Aspects of Current Management] Strategies for blood management in orthopaedic and trauma surgery

Lemaire, R. — 2008-08-31

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.

[Aspects of Current Management] Fracture healing in HIV-positive populations

2008-07-31

Highly active anti-retroviral therapy has transformed HIV into a chronic disease with a long-term asymptomatic phase. As a result, emphasis is shifting to other effects of the virus, aside from immunosuppression and mortality. We have reviewed the current evidence for an association between HIV infection and poor fracture healing.

The increased prevalence of osteoporosis and fragility fractures in HIV patients is well recognised. The suggestion that this may be purely as a result of highly active anti-retroviral therapy has been largely rejected. Apart from directly impeding cellular function in bone remodelling, HIV infection is known to cause derangement in the levels of those cytokines involved in fracture healing (particularly tumour necrosis factor-) and appears to impair the blood supply of bone.

Many other factors complicate this issue, including a reduced body mass index, suboptimal nutrition, the effects of anti-retroviral drugs and the avoidance of operative intervention because of high rates of wound infection. However, there are sound molecular and biochemical hypotheses for a direct relationship between HIV infection and impaired fracture healing, and the rewards for further knowledge in this area are extensive in terms of optimised fracture management, reduced patient morbidity and educated resource allocation. Further investigation in this area is overdue.