Orthopaedics

Orthopaedic surgery is a large and expanding speciality. There are approximately five million clinic attendances each year in this country and musculo-skeletal complaints are the commonest presentation in General Practice. This review examines three key areas within orthopaedics, fracture management, sports medicine and the new subspeciality of minimally invasive orthopaedics and highlights areas of recent advancement, significant research and ongoing debate. FRACTURE MANAGEMENT Hip Fractures Around 60,000 patients are treated for hip fractures each year in the UK and the incidence is increasing (1).The majority are elderly, many have extensive co-morbidity and their treatment can often be surgically challenging and their post-operative recovery both lengthy and costly. Prevention The identification of risk factors is an important part of preventing these injuries. A case-control study from Belgium found that the greatest risk factor was the patient’s self-perceived safety of their residence (2). If subjects thought that their residence was unsafe in which to perform the activities of daily living, this was associated with a sixfold increase in hip fracture risk. The risk was also increased after any two previous fractures, or any tendency to fall within the past year or the chronic use of psychotropic drugs. The ability to read a newspaper was protective.The predictive nature of previous fractures has been confirmed by a study from Edinburgh (3) which calculated the risk of refracture after a low-energy fracture (ie one that results from a fall from or below standing height), to be 3.89, hence the necessity for preventive measures. Hip fracture prevention strategies such as fall prevention programs, weight-bearing and resistance exercises, hip protectors and use of calcium and vitamin D can all reduce hip fracture risk (2,4). Surgery Traditionally, intracapsular hip fractures have been treated by hemiarthroplasty whilst extracapsular fractures undergo internal fixation. The different strategies are based upon the relatively increased risk of avascular necrosis of the femoral head after intracapsular fracture, although this didactic division is now coming under renewed scrutiny. Rogmark et al conducted a prospective, randomised trial comparing internal fixation against hemiarthroplasty for the treatment of Garden 3 or 4 (See Box 1) subcapital fractures in 409 patients aged 70 or over (5). Two years after surgery, 43% of the internal fixation procedures had failed compared to only 6% of the hemiarthroplasties. The internal fixation group were also more likely to have impaired walking (36% v 25%) and severe pain (6% v 1.5%) compared to those who had hemiarthroplasty.There was no difference in mortality. The same authors conducted a further study including patients who were at least 80 years old, had evidence of dementia or were resident in a nursing home or other institution (6), most of whom were excluded from the previous trial. 103 patients with Garden 3 or 4 femoral neck fractures underwent hemiarthroplasty and were compared to a smaller control group undergoing internal fixation. There were no differences in complications, length of hospital stay, in-hospital mortality or ability to return home.The one-year mortality rates were also similar. Hemiarthroplasty however yielded a much lower failure rate (6% v 26%). The authors recommend that all patients over 70 with femoral neck fractures undergo primary hemiarthroplasty, to avoid the risks of revision surgery in this highrisk population when internal fixation fails. A meta-analysis of trials comparing hemiarthroplasty with internal fixation also showed arthroplasty to have lower revision rates, but greater infection rates, blood loss, length of operation and possibly early mortality rates (7), a finding confirmed by Su et al who reported an increased inhospital death rate for patients treated with hemiarthroplasty (8). Box 1.The Garden Classification. Maj J H Bird MRCS(Ed) RAMC Trauma Section, DSTL Porton Down, Wiltshire, SP4 0JQ WHAT’S NEW IN . . .