The next critical role of orthopedic registries The Scandinavian ACL registries 2004–2007: baseline epidemiology Cement augmentation of the Proximal Femoral Nail Antirotation (PFNA) - A multicentre randomized controlled trial. Implant-Related Fractures of the Femur Following Hip Fracture Surgery A new short uncemented, proximally fixed anatomic femoral implant with a prominent lateral flare: design rationals and study design of an international clinical trial [Two-year results of a modular short hip stem prosthesis--a prospective study]. A randomized study on migration of the Spectron EF and the Charnley flanged 40 cemented femoral components using radiostereometric analysis at 2 years Which Implant Is Better for Treating Reverse Obliquity Fractures of the Proximal Femur: A Standard or Long Nail? Is the Proximal Femoral Nail a Suitable Implant for Treatment of All Trochanteric Fractures? Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis: the U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry. Bone remodelling after femoral short stem implantation in total hip arthroplasty: 1-year results from a randomized DEXA study Locking intramedullary nails and locking plates in the treatment of two-part proximal humeral surgical neck fractures: a prospective randomized trial with a minimum of three years of follow-up. A comparative study of screw and helical proximal femoral nails for the treatment of intertrochanteric fractures. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. Maintenance of bone mineral density after implantation of a femoral neck hip prosthesis Early functional results after Hemiarthroplasty for femoral neck fracture: a randomized comparison between a minimal invasive and a conventional approach Comparative study of the proximal femoral nail antirotation versus the reconstruction nail in the treatment of comminuted proximal femoral fracture. Expandable Proximal Femoral Nails (EPFNs) in Elderly Patients Retracted: Outcome of Short Proximal Femoral Nail Antirotation and Dynamic Hip Screw for Fixation of Unstable Trochanteric Fractures. A Randomised Prospective Comparative Trial Conventional versus computer-navigated TKA: a prospective randomized study Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. A Comparative study of the Dynamic Hip Screw, the Cemented Bipolar Hemiarthroplasty and the Proximal Femoral Nail for the Treatment of Unstable Intertrochanteric Fractures. [Proximal femoral intramedullary nail versus DHS plate for the treatment of intertrochanteric fractures. A prospective analysis]. Percutaneous compression plate versus proximal femoral nail anti-rotation in treating elderly patients with intertrochanteric fractures: a prospective randomized study The direct anterior approach in hemiarthroplasty for displaced femoral neck fractures Remodeling of Bone around Hydroxyapatite-Coated Femoral Stems* Is Locking Nailing of Humeral Head Fractures Superior to Locking Plate Fixation? A review of current surgical practice in the operative treatment of proximal humeral fractures Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators. Antibiotics in trauma and orthopedic surgery -- a primer of evidence-based recommendations. The dynamics of proximal femoral nails: a clinical comparison between PFNA and Targon PF. Cemented versus Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures A randomised comparison of AMBI, TGN and PFN for treatment of unstable trochanteric fractures The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae Hemiarthroplasty of the hip with and without cement: a randomized clinical trial. A Comparative Study of 3-Dimensional Titanium Versus 2-Dimensional Titanium Miniplates for Open Reduction and Fixation of Mandibular Parasymphysis Fracture Hydroxyapatite-Coated Total Hip Femoral Components in Patients Less Than Fifty Years Old. Clinical and Radiographic Results after Five to Eight Years of Follow-up* Early complications of anterior supine intermuscular total hip arthroplasty. Total knee arthroplasty with an oxidised zirconium femoral component: ten-year survivorship analysis. Displaced proximal humeral fractures: operative versus non-operative treatment—a 2-year extension of a randomized controlled trial Randomized controlled trial of goal-directed haemodynamic treatment in patients with proximal femoral fracture. Proximal femoral nails compared with reverse distal femoral locking plates in intertrochanteric fractures with a compromised lateral wall; a randomised controlled trial The Exeter femoral stem continues to migrate during its first decade after implantation Bone and muscle mass after femoral neck fracture Three-year evaluation of single-tooth implants restored 3 weeks after 1-stage surgery. Flapless Versus Traditional Dental Implant Surgery: Long-Term Evaluation of Crestal Bone Resorption. Modified direct anterior approach in minimally invasive hip hemiarthroplasty in a geriatric population: a feasibility study and description of the technique
There is an urgent need for the introduction of new implant technology in orthopedic surgery to be conducted in a more controlled manner than in the past . Inadequate regulation and lack of effective post-market surveillance have meant that patients have not been protected from potentially harmful implants and procedures . Compounding the problem is a lack of question ing , a lack of critical appraisal , and lack of a requirement for clinical evidence by both surgeons and manufacturers before large-scale introduction of new technology to the market . There is a long and growing history of failed innovation , demonstrated by the failure or recall of individual products such as Boneloc ( bone cement ) , The Capital Hip ( total hip arthroplasty ) , and the ASR hip system ( total hip arthroplasty ) among others , as well as whole classes of devices such as large-head metal-on-metal bearings . This demonstrates simple , yet severe flaws in the mechanisms that should protect patients from increased risk associated with introduction of new technology . Insufficient or inadequate pre clinical data , a lack of clinical data from timely RSA ( radiostereometric analysis ) studies , and limited larger , multicenter cohort studies prior to general release all increase the risk to patients . The 510k process , where the majority of so-called innovative new design s have been cleared or approved by FDA - or CE-notified bodies for clinical use , is based on similarities to previously used implants . In the 510k process , there is no requirement for specific clinical evidence , so manufactures have not obtained clinical data . Registry post-market surveillance has proven to be a powerful method for detection of increased risk of implant failure , but this is not available in all countries . When registries do identify poor-performing devices , regulators and manufacturers are often slow to respond . The main problem with the current approach to the introduction of new technology is the inability to identify unanticipated failures before wider release ( Bauer 1992 ) . It is 20 years since the stepwise introduction of new implants was first described ( Malchau 1995 ) . The basic concept of this approach is that the smallest possible numbers of patients ( after sufficient pre clinical testing ) are exposed to the implant prior to general release . Stepwise introduction uses a combination of ( 1 ) outcome measurements with high-precision metrics in small cohorts , such as RSA , and ( 2 ) limited clinical introduction in a larger cohort , prospect ively monitoring outcomes and revisions . Adoption of this concept would certainly have reduced the large number of poor-performing new implants introduced in recent years . The concept has , however , never been implemented due to lack of support from surgeons , manufacturers , and regulatory authorities . Now trends have changed , with increasing focus on implementing an effective approach to pre-release clinical assessment . The ongoing work and discussion s in the International Society of Arthroplasty Registries ( ISAR ) , the reports from the Australian Orthopaedic Association total joint registry , and the actions taken in the UK to put a “ beyond compliance ” program into action will facilitate a more cautious market introduction . In addition , the Arthroplastywatch project ( www.arthroplastywatch.com ) is in action : data are collected on the web through a specially developed search routine . Based on examination in several steps using medical and statistical expertise , a caution could be warranted or a warning declared . These combined initiatives say one thing : that close monitoring of new implants by well-established registries during a phase of controlled introduction must be a universal requirement . We propose a structured model for clinical trials involving 4 levels : ( 1 ) a pure observational study using reoperation data from multiple registries , as shown in several papers by the Nordic Arthroplasty Register Association ( NARA ) ; ( 2 ) patient-reported outcome measures , either from national implant registries or from other registries for specific studies ; ( 3 ) radiographic data plus other parameters such as blood levels of metal ions , based on specific needs for a new technology ; and ( 4 ) options for r and omized studies with use of , for example , RSA in the evaluation . The cornerstone in this structural model should be the exp and ed use of existing and future registries with a high degree of coverage and completeness . While registries have a strong tradition in arthroplasty surgery , this is not as well developed in other areas of orthopedic surgery . It is the responsibility of orthopedic surgeons and their professional bodies to support and implement registries where they can be of benefit . The arthroplasty registry experience has shown that it is possible to use registries to effectively monitor the introduction of new technology . Without this registry-based surveillance , identification of many of the failed innovations would have been delayed or might even have gone unrecognized . It is encouraging that registries in fracture surgery are now emerging , where implants are inserted in large and increasing numbers . Finally , implant performance is potentially confounded by the technical difficulty of inserting the implant , the knowledge and abilities of the surgeon inserting them , and the complexity of the cases . Many registries monitor performance at the surgeon level . This together with continuous education and training in how to use new implants should be an integral part of the process of a more cautious market introduction . If training is linked in with the stepwise introduction , it will be possible to identify the need for and the extent of training . Our proposed regulatory change to require registry-based monitoring of new implants during the phase of limited introduction must be accompanied by a change in the way we think and act as orthopedic surgeons . In the training of future orthopedic surgeons , emphasis must be placed on developing a healthy skepticism to innovation , on recognizing the need for evidence -based introduction , and on building a culture holding the view that reporting to a registry is imperative . The registries will then be able to offer back data to enable surgeons to choose the best clinical practice . To increase innovation and to ensure that innovation is effective and beneficial , the role of registries should be exp and ed . The registries should not undertake the role of a regulatory authority , but in compliance with the industry and the orthopedic community they should ensure that a more cautious approach is used when new technology is introduced . This could lead to a better balance between the inborn conservatism that a registry represents and the continuous need for innovation . The independence , infrastructure , and expertise of the registries can be used more fully to optimize how new implants are introduced . All stakeholders need to join to ensure that first and foremost , we do no harm Background and purpose No prospect i ve surveillance systems have been available for monitoring the outcome of  cruciate ligament surgery in Sc and inavia ( Denmark , Norway , and Sweden ) . In the present paper we describe the Sc and inavian ACL registries including their main function , similarities , and preliminary baseline results . Methods The Sc and inavian registries were established in 2004 ( Norway ) and 2005 ( Denmark and Sweden ) . The Danish and Swedish registries were originally based on the Norwegian registry , and there is no overriding difference between the three . In Denmark , all hospitals and clinics are legally bound to report to an approved national data base . In Norway and Sweden , the registries are based on voluntarily reporting by surgeons . Results The annual incidence of primary ACL reconstructions  is higher in Denmark than in Norway , except in females younger than 20 years . Among Sc and inavian surgeons , there is a similar approach to the patients . Differences do , however , exist regarding choice of grafts , choice of implants , and choice of treatment of simultaneous meniscal and cartilage injuries ; the proportion of ACL reconstructions performed as outpatient surgery ; and the use of prophylactic anticoagulation . Clinical ly , the preoperative KOOS scores are not significantly different between the Sc and inavian registries , except that Denmark reports more symptoms both pre- and postoperatively . Interpretation The Sc and inavian national ACL registries will generate new data about ACL reconstructions . They will contribute important knowledge regarding ACL epidemiology . They will be the only source of data on the performance of a wide range of different implants and techniques . In addition , they will hopefully have an impact on the selection of methods for ACL reconstructions in Sc and inavia and elsewhere INTRODUCTION New implant design s like the Proximal Femoral Nail Antirotation ( PFNA ) were developed to reduce failure rates in unstable pertrochanteric fractures in the elderly . St and ardized implant augmentation with up to 6 mL of polymethylmethacrylate ( PMMA ) cement has been introduced to enhance implant anchorage by increasing the implant-bone interface in osteoporotic bone conditions . Biomechanically , loads to failure were significantly higher with augmentation . The primary objective of this study was to compare the mobility of patients with closed unstable trochanteric fractures treated by PFNA  either with or without cement augmentation . PATIENTS AND METHODS A prospect i ve multicentre , r and omized , patient-blinded trial was conducted with ambulatory patients aged 75 or older who sustained a closed , unstable trochanteric fracture . Surgical fixation had to be performed within 72 h after admission . Outcomes were evaluated at baseline , during surgery , 3 to 14 days after surgery , 3 months , 6 months , and 12 months after surgery . To evaluate the primary objective , patients ' walking speed was assessed by the Timed Up and Go ( TUG ) test . Secondary objectives included the analysis of implant migration assessed on radiographs , quality of life measured by the Barthel Index , mobility measured by the Parker Mobility Score , and complications . RESULTS Of 253 r and omized patients , 223 patients were eligible : 105 patients were allocated to the  PFNA Augmentation group and 118 to  PFNA group .  At 3 to 14 days after surgery , there was no statistical significant difference in mean walking speed between the treatment groups . For the secondary objectives , also no statistical significant differences were found . However , no patient in the PFNA Augmentation group had a reoperation due to mechanical failure or symptomatic implant migration compared to 6 patients in the PFNA group . CONCLUSIONS Augmentation of the PFNA blade did not improve patients ' walking ability compared to the use of a non-augmented PFNA but might have the potential to prevent reoperations by strengthening the osteo synthesis construct Background : Most hip fractures are treated surgically , with use of either internal fixation or prosthetic replacement of the femoral head . The presence of these implants increases the risk of a later femoral fracture in susceptible osteoporotic patients . The purpose of this study was to analyze the incidence of and risk factors for implant-related fractures of the femur after previous hip fracture surgery . Methods : Over a ten-year period from January 1988 to December 1997 , 6230 patients ( median age , eighty-two years ; male : female ratio , 1247:4983 ) who sustained a total of 6696 hip fractures were admitted to the Edinburgh Orthopaedic Trauma Unit . Demographic information on the patients and details of the original treatment of the hip fracture were prospect ively coded and entered into a trauma data base . All subsequent readmissions due to a femoral fracture related to the implant were prospect ively audited and extracted for the purpose s of this study . Results : One hundred and forty-one patients sustained an ipsilateral fracture of the femur at a median of twenty-four weeks following the original hip fracture surgery . Survivorship analysis of the hip fracture population revealed an overall rate of subsequent femoral fracture of 2.9 % at five years , which increased to 5.1 % at ten years . The median age and gender distribution of the patients who sustained a subsequent femoral fracture were similar to those of the hip fracture population as a whole . Two-thirds of the fractures propagated from the tip of the implant . Analysis of the subsequent fractures according to the type of implant used to treat the original fracture revealed considerable differences in incidence . The incidence was relatively high in the patients initially treated with a Gamma nail ( 18.74 fractures per 1000 person-years ) or a cementless hemiarthroplasty ( 11.72 per 1000 person-years ) and was relatively low in those treated with a compression hip screw ( 4.46 per 1000 person-years ) , cannulated screws ( 4.50 per 1000 person-years ) , or a primary arthroplasty with cement ( 6.2 per 1000 person-years ) . The highest incidence of fracture was seen in the patients who had required an arthroplasty with cement as a revision procedure following failure of a primary implant ( 22.39 per 1000 person-years ) . Conclusions : Implant-related fractures following hip fracture surgery are more common than has previously been appreciated . The risk of later ipsilateral femoral fracture is increased by the use of a Gamma nail or a cementless hemiarthroplasty to treat the original hip fracture Background Anatomic short femoral prostheses with a prominent lateral flare have the potential to reduce stress-shielding in the femur through a more physiological stress distribution to the proximal femur . We present the design rationale of a new short uncemented , proximally fixed anatomic femoral implant and the study design of a prospect i ve multi-centre trial to collect long-term patient outcome and radiographic follow up data . Methods A prospect i ve surveillance study ( trial registry NCT00208555 ) in four European centres ( UK , Italy , Spain and Germany ) with a follow up period of 15 years will be executed . The recruitment target is 200 subjects , patients between the ages of 18 and 70 admitted for primary cementless unilateral THA will be included . The primary objective is to evaluate the five-year survivorship of the new cementless short stem .  The secondary objectives of this investigation are to evaluate the long term survivorship and the clinical performance of the implant , the impact on the subjects health related Quality of Life and the affect of the prosthesis on bone mineral density . Peri- and postoperative complications will be registered . Clinical and radiographic evaluation of prosthesis positioning will be done post-operatively and at 3 , 6 , 12 , 24 , 60 , 120 and 180 months follow up . Discussion Shortening of the distal stem can maximise bone and soft tissue conservation . New stem types have been design ed to improve the limitations of traditional implants in primary THA . A new , uncemented femoral short stem is introduced in this paper . A long-term follow up study has been design ed to verify stable fixation and to research into the clinical outcome . The results of this trial will be presented as soon as they become available AIM The short-term results of a prospect i ve , consecutive series of 50 cementless modular short hip stem endoprostheses  are reported . METHOD 48 cases were available for clinical and radiological follow-up at an average time of 2.4 years post-op . One patient did not consent to a follow-up investigation , 1 early revision was necessary 4 weeks post-op after a fall precipitating a periprosthetic fracture . RESULTS The average age at the time of THA was 54 years and the Harris hip score reached 95 points at the time of follow-up . One implant had aseptic loosening and 1 implant was revised due to a failure of the modular titanium neck adapter . An equal number of patients received modular neck adapters with neutral or 7.5 degrees retroversion . No 140 degrees neck and no anteverted neck adapters were used . Radiological results of the 2/3 porous coated hip stem showed a metaphyseal bone remodelling with hypertrophies in coated Gruen zones 3 ( 17 % ) and 6 ( 46 % ) and marked spot welds and increased bone density ( 86 % ) in the distal area of the coating . Primary implant migration between 2 and 10 mm was present in 7 cases due to a low osteotomy and implant position combined with an implant undersizing and lack of proximal-lateral support . At the time of the last follow-up these cases had no clinical symptoms with an average HHS of 96 points and with full bony integration . CONCLUSION Our results support the use of the investigated short hip stem for THA when the femoral bone quality and morphology support the metaphyseal anchoring concept . The surgical technique must avoid a stem position without proximal-lateral cortical contact to the femoral osteotomy , as this reduces primary implant stability . Further follow-up is necessary to vali date the long-term success of this procedure Background and purpose We performed a r and omized study to determine the migration patterns of the Spectron EF femoral stem and to compare them with those of the Charnley stem , which is regarded by many as the gold st and ard for comparison of implants due to its extensive documentation . Patients and methods 150 patients with a mean age of 70 years were r and omized , single-blinded , to receive either a cemented Charnley flanged 40 monoblock , stainless steel , vaquasheen surface femoral stem with a 22.2-mm head ( n = 30 ) or a cemented Spectron EF modular , matte , straight , collared , cobalt-chrome femoral stem with a 28-mm femoral head and a roughened proximal third of the stem ( n = 120 ) . The patients were followed with repeated radiostereometric analysis for 2 years to assess migration . Results At 2 years , stem retroversion was 2.3 ° and 0.7 ° ( p < 0.001 ) and posterior translation was 0.44 mm and 0.17 mm ( p = 0.002 ) for the Charnley group ( n = 26 ) and the Spectron EF group ( n = 74 ) , respectively . Subsidence was 0.26 mm for the Charnley and 0.20 mm for the Spectron EF ( p = 0.5 ) . Interpretation The Spectron EF femoral stem was more stable than the Charnley flanged 40 stem in our study when evaluated at 2 years . In a report from the Norwegian arthroplasty register , the Spectron EF stem had a higher revision rate due to aseptic loosening beyond 5 years than the Charnley . Initial stability is not invariably related to good long-term results . Our results emphasize the importance of prospect i ve long-term follow-up of prosthetic implants in clinical trials and national registries and a stepwise introduction of implants Background Reverse obliquity fractures of the proximal femur have biomechanical characteristics distinct from other intertrochanteric fractures and high implant failure rate when treated with sliding hip screws . Intramedullary hip nailing for these fractures reportedly has less potential for cut-out of the lag screw because of their loadbearing capacity when compared with extramedullary implants . However , it is unclear whether nail length influences healing . Questions / purpose sWe compared st and ard and long types of intramedullary hip nails in terms of ( 1 ) reoperation ( fixation failure ) , ( 2 ) 1-year mortality rate , ( 3 ) function and mobility , and ( 4 ) union rate . Methods We conducted a pilot prospect i ve r and omized controlled trial comparing st and ard versus long ( ≥ 34 cm ) intramedullary hip nails for reverse obliquity fractures of the proximal femur from January 2009 to December 2009 . There were 15 patients with st and ard nails and 18 with long nails . Mean age was 79 years ( range , 67–95 years ) . We determined 1-year mortality rates , reoperation rates , Parker-Palmer mobility and Harris hip scores , and radiographic findings ( fracture union , blade cut-out , tip-apex distance , implant failure ) . Minimum followup was 12 months ( mean , 14 months ; range , 12–20 months ) . Results We found no difference in reoperation rates between groups . Two patients ( both from the long-nail group ) underwent revision surgery because of implant failure in one and deep infection in the other . There was no difference between the st and ard- and long-nail groups in mortality rate ( 17 % versus 18 % ) , Parker-Palmer mobility score ( five versus six ) , Harris hip score ( 74 versus 79 ) , union rate ( 100 % in both groups ) , blade cut-out ( zero versus one ) , and tip-apex distance ( 22 versus 24 mm ) . Conclusions Our preliminary data suggest reverse obliquity fractures of the trochanteric region of the femur can be treated with either st and ard or long intramedullary nails . Level of Evidence Level II , therapeutic study . See Instructions for Authors for a complete description of levels of evidence We review ed 155 consecutive patients who were treated with a proximal femoral nail from 1997 to 2001 to determine the rate of implant specific complications . Results were stratified according to fracture type and surgeon experience to determine which problems occurred in these groups . One year postoperative followup was available for 129 of 132 surviving patients ( 98 % ) . Failure of fixation occurred in three patients ( 2 % ) , and a femoral shaft fracture occurred in one patient ( 0.7 % ) . Fixation failures included one cutout , one delayed fracture healing , and one lateral displacement of the antirotation screw . The total reoperation rate was high ( 12 % ) mainly because of hardware removals , which occurred in 13 patients ( 8.6 % ) . Stratification of results showed that hematomas and iliotibial tract irritation occurred more commonly with lesser surgical experience . General complications and intraoperative problems were seen more often with subtrochanteric fractures . Because the high reoperation rate with the proximal femoral nail is a concern , extramedullary devices continue to be the preferred implants for treatment of stable trochanteric fractures . The low rates of femoral shaft fractures and failure of fixation suggest the proximal femoral nail is useful for treatment of unstable trochanteric and subtrochanteric fractures . Level of Evidence : Therapeutic study , Level IV ( case series ) . See the Guidelines for Authors for a complete description of levels of evidence OBJECTIVES The objective was to define the characteristics of a real-world patient population treated with transcatheter aortic valve implantation ( TAVI )  , regardless of technology or access route , and to evaluate their clinical outcome over the mid to long term . BACKGROUND Although a substantial body of data exists in relation to early clinical outcomes after TAVI , there are few data on outcomes beyond 1 year in any notable number of patients . METHODS The U.K. TAVI ( United Kingdom Transcatheter Aortic Valve Implantation ) Registry was established to report outcomes of all TAVI procedures performed within the United Kingdom . Data were collected prospect ively on 870 patients undergoing 877 TAVI procedures up until December 31 , 2009 . Mortality tracking was achieved in 100 % of patients with mortality status reported as of December 2010 . RESULTS Survival at 30 days was 92.9 % , and it was 78.6 % and 73.7 % at 1 year and 2 years , respectively . There was a marked attrition in survival between 30 days and 1 year . In a univariate model , survival was significantly adversely affected by renal dysfunction , the presence of coronary artery disease , and a nontransfemoral approach ; whereas left ventricular function ( ejection fraction < 30 % ) , the presence of moderate/severe aortic regurgitation , and chronic obstructive pulmonary disease remained the only independent predictors of mortality in the multivariate model . CONCLUSIONS Midterm to long-term survival after TAVI was encouraging in this high-risk patient population , although a substantial proportion of patients died within the first year Introduction Short stem prostheses have been developed to preserve proximal femoral bone stock . This prospect i ve , r and omized study compared periprosthetic bone remodelling following short and straight stem implantation 1 year after surgery . Material s and methods One hundred and forty-four consecutive patients undergoing total hip arthroplasty were r and omized to either a Fitmore short or a cementless straight stem ( both Zimmer , Winterthur , Switzerl and ) . Periprosthetic bone mineral density ( BMD ) was measured using dual-energy X-ray absorptiometry performed the day before surgery and at 7 days , 3 months and 1 year postoperatively . Furthermore , the HHS and the WOMAC were obtained . Results One hundred and thirty-eight patients completed 1-year follow-up . Periprosthetic BMD changes at 1 year were most pronounced in the proximal medial region of interest ( ROI ) 7 with −17.2 % after short stem and −16.7 % after straight implantation ( p = 0.67 ) . However , there was significantly less BMD reduction in ROI 6 following short ( −4.7 % ) versus straight stem ( −10.8 % ) implantation ( p = 0.01 ) . There were no significant differences between the two groups in terms of the HHS and the WOMAC either before or after surgery . Conclusion One year after surgery , both stems showed an implant-specific periprosthetic bone remodelling . Nevertheless , proximal load transfer was more pronounced after short stem implantation than with a straight stem BACKGROUND locking intramedullary nails and locking plates specially design ed for proximal humeral fractures are widely used . The purpose of our study was to compare the outcomes between these two types of implants in patients with a two-part surgical neck fracture . The advantages and shortcomings of each method were analyzed . METHODS a prospect i ve r and omized study was performed . Fifty-one consecutive patients with a fresh two-part surgical neck fracture were r and omized to be treated with a locking intramedullary nail ( n = 25 ) or a locking plate ( n = 26 ) . Clinical and radiographic assessment s were conducted at one year and three years after the surgery . A visual analog scale ( VAS ) was used to assess shoulder pain . The American Shoulder and Elbow Surgeons ( ASES ) scores and Constant-Murley scores were recorded to evaluate shoulder function . RESULTS fracture union was achieved in all patients within three months after the surgery . At one year postoperatively , a significant difference ( p = 0.024 ) was found with regard to the complication rate between the locking plate group ( 31 % ) and the locking nail group ( 4 % ) . The average ASES score , median VAS score , and average strength of the supraspinatus were significantly better in the locking plate group ( 90.8 compared with 83.6 points [ p = 0.021 ] , 1.0 compared with 0.5 point [ p = 0.042 ] , and 77.4 % compared with 64.3 % [ p = 0.032 ] ) . At three years postoperatively , no significant difference could be found in terms of any parameter between the two groups . Significant improvement in the VAS pain scores , ASES scores , and Constant-Murley scores were found between the one-year and three-year follow-up examinations in each group . CONCLUSIONS satisfactory results can be achieved with either implant in the treatment of two-part proximal humeral surgical neck fractures . There was no difference regarding the ASES scores between these two implants at the time of the final , three-year follow-up . The complication rate was lower in the locking intramedullary nail group , while fixation with a locking plate had the advantage of a better one-year outcome . LEVEL OF EVIDENCE therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence The goal of this study was to compare treatment outcomes of screw proximal femoral nails and helical proximal femoral nails and to investigate the effectiveness of helical proximal femoral nails for the treatment of intertrochanteric fractures . Forty patients with intertrochanteric fractures were treated at our institution between January 2005 and January 2007 , with a minimum follow-up of 1.5 years . Seventeen patients were treated with screw proximal femoral nails ( mean patient age , 67 years ; age range , 45 - 89 years ; men : women ratio , 3:14 ) , and 23 were treated with helical proximal femoral nails ( mean patient age , 74 years ; age range , 64 - 91 years ; men : women ratio , 6:17 ) . We evaluated mean operation time , amount of bleeding , time to ambulation , average union period , changes in neck shaft angle , and complications , and performed radiographic review s , telephone interviews  , and direct  contact interviews  at an outpatient clinic . We evaluated postoperative function and mobility using social function scores and mobility scores .  Helical proximal femoral nails produced better results in terms of social function scores , mobility scores , and complication rates with statistical significance . No significant differences were found between the 2 nails in terms of mean operation time , amount of bleeding , average union period , time to ambulation , or neck shaft angle changes .  Screw proximal femoral nails and helical proximal femoral nails are suitable implants for intertrochanteric fractures , but helical proximal femoral nails are better in terms of functional aspects and complication rates BACKGROUND Controversy exists with regard to whether to treat AO/OTA 31-A2 fractures of the proximal part of the femur with an intramedullary device or an extramedullary device . A prospect i ve , r and omized , controlled trial was performed to compare the outcome of treatment of these unstable fractures of the proximal part of the femur with either a sliding hip screw or a long gamma nail . METHODS Two hundred and ten patients presenting with an AO/OTA 31-A2 fracture of the proximal part of the femur were r and omized , at the time of admission , to fixation with use of either a long gamma nail or a sliding hip screw .  The primary outcome measure was reoperation within the first postoperative year . Secondary measures included mortality , length of hospital stay , transfusion rate , change in mobility and residence , and quality of life as measured with the EuroQol 5D outcome score . RESULTS There was no significant difference between the reoperation rates for the two groups . In total , five patients ( three from the long-gamma-nail group and two from the sliding-hip-screw group ) underwent revision surgery because of cut-out . Tip-apex distance was found to correlate with the implant cut-out rate . There was no significant difference between the two groups in terms of the EuroQol 5D outcome scores , the mortality rates after correction for the mini-mental score , or any of the secondary outcome measures . CONCLUSIONS When compared with the long gamma nail , the sliding hip screw should remain the gold st and ard for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur because it is associated with similar outcomes with less expense Background Stress shielding of the proximal femur has been observed in a number of conventional cementless implants used in total hip arthroplasty .  Short femoral-neck implants are cl aim ing less interference with the biomechanics of the proximal femur . The goal of this study was to investigate the changes of bone-mineral density in the proximal femur and the clinical outcome after implantation of a short femoral-neck prosthesis . Methods We prospect ively assessed the clinical outcome and the changes of bone mineral density of the proximal femur up to one year after implantation of a short femoral neck prosthesis in 20 patients with a mean age of 47 years ( range 17 to 65 ) . Clinical outcome was assessed using the Harris Hip Score . The WOMAC was used as a patient-relevant outcome -measure . The bone mineral density was determined using dual energy x-ray absorptiometry , performed 10 days , three months and 12 months after surgery . Results The Harris Hip Score improved from an average preoperative score of 46 to a postoperative score at 12 months of 89 points , the global WOMAC index from 5,3 preoperatively to 0,8 at 12 months postoperatively . In contrast to conventional implants , the DEXA-scans overall revealed a slight increase of bone mineral density in the proximal femur in the 12 months following the implantation . Conclusion The short femoral neck stem lead to a distinct bone reaction . This was significantly different when compared to the changes in bone mineral density reported after implantation of conventional implants Background A minimal invasive approach for elective hip surgery has been implemented in our institution in the past . It is widely hypothesized that implanting artificial hips in a minimal invasive fashion decreases surgical trauma and is helpful in the rehabilitation process in elective hip surgery . Thereby geriatric patients requiring emergency hip surgery also could theoretically benefit from a procedure that involves less tissue trauma . Methods Sixty patients who sustained a fractured neck of femur were r and omly assigned into two groups . In the minimal invasive arm , the so called “ direct anterior approach ” ( DAA ) was chosen , in the conventional arm the Watson-Jones-Approach was used for implantation of a bipolar hemi-arthroplasty . Primary outcome parameter was the mobility as measured by the four-item-Barthel index . Secondary outcome parameters included pain , haemoglobin-levels , complications , duration of surgery , administration of blood transfusion and external length of incision . Radiographs were evaluated . Results A statistically significant difference ( p = 0,009 ) regarding the mobility as measured with the four-item Barthel index was found at the 5th postoperative day , favouring the DAA . Evaluation of the intensity of pain with a visual analogue scale ( VAS ) showed a statistically significant difference ( p = 0,035 ) at day 16 . No difference was evident in the comparison of radiographic results . Conclusions Comparing two different approaches to the hip joint for the implantation of a bipolar hemi-arthroplasty after fractured neck of femur , it can be stated that mobilization status is improved for the DAA compared to the WJA when measured by the four-item Barthel index , there is less pain as measured using the VAS . There is no radiographic evidence that a minimal invasive technique leads to inferior implant position . Level of Evidence : Level II therapeutic study The purpose of our study was to compare the proximal femoral nail antirotation ( PFNA ; Synthes , Paoli , Pennsylvania ) with a reconstruction nail ( Recon ; Zimmer , Warsaw , Indiana ) in the treatment of comminuted proximal femoral fractures . Between 2003 and 2010 , twenty-three consecutive patients with AO/Orthopaedic Trauma Association 31-A3 fractures combined with proximal 32 fractures who had a minimum 18-month follow-up were evaluated retrospectively . There were 10 patients ( age range , 18 - 74 years ) in the Recon nail group and 13 patients ( age range , 22 - 90 years ) in the PFNA nail group . Patients treated with Recon nails experienced a longer operation time ( P=.006 ) and more blood loss ( P=.012 ) than patients treated with the PFNA nail . On postoperative radiographs , the change in the neck-shaft angle was 8.8 ° in the Recon nail group and 4.7 ° in the PFNA nail group ( P=.048 ) . The fracture union time averaged 31.8 weeks in the Recon nail group and 21.5 weeks in the PFNA nail group ( P=.148 ) . More patients in the Recon nail group underwent major or minor reoperation ( P=.038 ) compared with the PFNA nail group . No implant failure occurred in either group . The functional results were similar in the 2 groups . For the treatment of comminuted proximal femoral fractures , use of either the PFNA and Recon nail is clinical ly effective . However , the PFNA nail provides a shorter operation time , less blood loss , and better realignment ability and reduces the incidence of reoperation . Therefore , the PFNA nail can be considered a better device than the Recon nail ABSTRACT Purpose : The purpose was to study the performance of exp and able proximal femoral nails ( EPFNs ) for the treatment of unstable intertrochanteric fractures in elderly patients . Patients and methods : Eighty-four patients were treated with a newly design ed EPFN and followed up for one year . Results : The mean operating time was 50.1 ± 3.2 min and the mean blood loss was 112.3 ± 5.3 ml . Patients were treated with EPFNs of 220 mm ( n = 24 ) , 240 mm ( n = 59 ) , and 340 mm ( n = 1 ) length . At six months postoperatively , the Harris Hip Score was 74.5 ± 5.3 . At the end of follow up , 75 % of patients completely recovered their preoperative function and resumed their normal activities . Seven patients died within one year postoperatively . During the operation , one patient experienced proximal femoral diaphyseal slight crack fracture . This crack fracture was treated by using a long EPFN ( 340 mm ) . Two patient developed screw cut-outs , which were solved by reoperation . And one developed deep infection resolved favorably by the appropriate antibiotic treatment . Implant failure , deep venous thrombosis , fat embolism , secondary fracture , and nonunion were not encountered . Conclusions : In conclusion , the results of the EPFNs were satisfactory in most elderly patients with unstable intertrochanteric fracture . However , during the inflation period , the pressure on the nail must be monitored carefully in order to prevent a crack fracture A prospect i ve , r and omised , controlled trial was performed to compare the outcome of treatment of unstable trochanteric fractures with either a short proximal femoral nail antirotation ( PFNA ) or dynamic hip screw ( DHS ) .  Eighty one patients with unstable fracture of the proximal part of the femur were r and omised , at the time of admission , for fixation with either a short PFNA ( n=42 ) or DHS ( n= 39 ) . The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year . Operative time , fluoroscopy time , blood loss , and any intra-operative complication were recorded for each patient . Clinical and radiological follow-up was undertaken for a minimum of 36 months . Any changes in the position of the implant or fixation failure were recorded . Hip range of motion , pain in the hip or thigh and return to work were used to compare the outcomes . There was no significant difference between 1 year mortality rates for the two groups . The mean operative time was significantly less in PFNA group ( 25 min ) than in the DHS group ( 38 min ) . Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss . Six patients in DHS group had implant failure while none experienced this in PFNA group . The PFNA group had a better functional outcome than the DHS group Purpose The purpose of this study was to assess the midterm results of total knee arthroplasty ( TKA ) implanted with  a specific computer navigation system in a group of patients ( NAV ) and to assess the same prosthesis implanted with the conventional technique in another group ( CON ) ; we hypothesized that computer navigation surgery would improve implant alignment , functional scores and survival of the implant compared to the conventional technique . Methods From 2008 to 2009 , 225 patients were enrolled in the study and r and omly assigned in CON and NAV groups ; 240 consecutive mobile-bearing ultra-congruent score ( Amplitude , Valence , France ) TKAs were performed by a single surgeon , 117 using the conventional method and 123 using the computer-navigated approach .  Clinical outcome assessment was based on the Knee Society Score ( KSS ) , the Hospital for Special Surgery Knee Score and the Western Ontario Mac Master University Index score . Component survival was calculated by Kaplan – Meier analysis . Results Median follow-up was 6.4 years ( range 6–7 years ) . Two patients were lost to follow-up . No differences were seen between the two groups in age , sex , BMI and side of implantation . Three patients of CON group referred feelings of instability during walking , but clinical tests were all negative . NAV group showed statistical significant better KSS Score and wider ROM and fewer outliers from neutral mechanical axis , lateral distal femoral angle , medial proximal tibial angle and tibial slope in post-operative radiographic assessment . There was one case of early post-operative superficial infection ( caused by Staph . Aureus ) successfully treated with antibiotics . No mechanical loosening , mobile-bearing dislocation or patellofemoral complication was seen . At 7 years of follow-up , component survival in relation to the risk of aseptic loosening or other complications was 100 % . There were no implant revisions . Conclusion This study demonstrates superior accuracy in implant positioning and statistical significant better functional outcomes of computer-navigated TKA . Computer navigation for TKAs should be used routinely in primary implants . Level of evidence II The proximal femoral nail ( PFN ) is a recently introduced intramedullary system , design ed to improve treatment of unstable trochanteric fractures of the hip . In a multicentre prospect i ve clinical study , the intra-operative use , complications and outcome of treatment using the  PFN ( n = 211 ) were compared with those using the gamma nail ( GN ) ( n = 213 ) . The intra-operative blood loss was lower with the PFN ( 220 ml v 287 ml , p = 0.001 ) . Post-operatively , more lateral protrusion of the hip screws of the PFN ( 7.6 % ) was documented , compared with the gamma nail ( 1.6 % , p = 0.02 ) . Most local complications were related to suboptimal reduction of the fracture and /or positioning of the implant . Functional outcome and consolidation were equal for both implants . Generally , the results of treatment of unstable trochanteric fractures were comparable for the PFN and GN . The pitfalls and complications were similar , and mainly surgeon- or fracture-related , rather than implant-related INTRODUCTION Fractures of the Intertrochanteric ( IT ) region are some of the most common fractures encountered by an orthopedic surgeon in his lifetime . With increase in life expectancy , the incidence of these fractures is also increasing . By 2040 , the incidence of these fractures is expected to double . Unstable IT fractures are a major cause of concern in the elderly due to the associated increase in morbidity and mortality . AIM The purpose of this study was to compare the intraoperative and postoperative parameters using the Dynamic Hip Screw ( DHS ) , the Cemented Bipolar Hemiarthroplasty ( BH ) and the Proximal Femoral Nail ( PFN ) for the management of unstable IT fractures . MATERIAL S AND METHODS Fifty patients , having unstable IT fractures with age more than 60 years were r and omly selected and were followed up averagely for 19 months ( 12- 30 months ) . The type of implant for a particular patient and a particular type of fracture was r and omly selected and the same surgical team treated all patients . Total number of 19 patients were operated using the DHS ( Group-1 ) , 13 using the BH ( Group-2 ) and 18 using the PFN ( Group-3 ) . All patients in the three groups were compared in terms of preoperative , intraoperative and postoperative parameters and functionally assessed using the Harris hip score and the mobility score of Parker and Palmer . RESULTS Patients operated using the PFN had significantly lower mean blood loss as compared to the other two groups . The mean days to unaided Full Weight Bearing ( FWB ) was significantly higher in patients treated by the DHS as compared to the other two groups . All three groups were comparable in terms of functional assessment . CONCLUSION Treatment of unstable IT fracture of femur is a matter open to debate . IT fractures of elderly must be treated with considering the age of the patient , mental status , bone quality , and the type of fracture . Level of Evidence according to OCEBM Levels of Evidence Working Group - Level 2 OBJECTIVE To show that patients with intertrochanteric fractures treated with a proximal femoral nail  have a better postoperative course than those treated with a DHS plate ( dynamic hip screw ) . METHODS Patients with a Boyd & Griffin type II intertrochanteric fracture were r and omly divided into two groups : a group of patients treated with a PFN and another one treated with a DHS plate . All patients were assessed at 2 , 4 , 8 and 16 weeks using the Harris scale and the visual analog scale pre- and postoperatively , as well as the operative time , incision size , intraoperative bleeding , onset of partial and /or total weight bearing , healing time , time to attain prior physical activity level , and radiographic result . RESULTS 32 patients met our criteria . The variables that had a significant reduction were : incision , operative time , postoperative pain according to the visual analog scale , onset of mobility , partial weight bearing and pain at 2 weeks . CONCLUSIONS The proximal femoral nail has better short-term outcomes than the DHS plate ; however , in the medium term both implants have the same outcomes Background The treatment and management of hip fracture poses a great challenge for clinicians in osteology and surgery . The aim of this study is to compare the clinical effectiveness of the percutaneous compression plate ( PCCP ) versus proximal femoral nail anti-rotation ( PFNA ) in the treatment of intertrochanteric fractures in elderly patients . Methods A prospect i ve r and omized study was carried out from January 2008 to October 2011 involving 90 elderly patients with intertrochanteric fractures ( 90 hips ) who underwent minimally invasive surgery using the PCCP or PFNA .  Evaluation variables , including operation time , intra- and perioperative blood loss , duration of hospital stay , incidence of postoperative complications , and final clinical outcomes by the end of follow-up , were used to compare the benefits of these two implants . Results Among 90 subjects , 45 received PCCPs and 45 received PFNAs . The baseline characteristics of the two groups were comparable . The median follow-up time was 16.9 months ( 12–24 months ) . In the PCCP group , the mean operative time was 53 min ( 40–75 min ) , and the mean intra- and perioperative blood losses were 100.7 ml ( 60–150 ml ) and 916 ml ( 433–1339 ml ) , respectively , which were significantly lower than those in the PFNA group . Nevertheless , there was no statistical difference in the incidence of postoperative complications and final clinical outcomes including pain complaints , range of motion of the hip , postoperative hip function at 12 months , and the recovery of walking ability to pre-injury status between these two implants . Conclusions Overall , the PCCP and PFNA appear to have similar clinical effects in treating elderly patients with intertrochanteric fractures , although the PCCP provided shorter operation times and less blood loss than PFNA . Both implants discussed were demonstrated to be ideal for the treatment of femoral intertrochanteric fractures in elderly patients Purpose Hip replacement is the most common treatment for displaced femoral neck fractures in the elderly , and minimally invasive surgery is popular in the field of orthopaedic surgery . This study evaluated the outcome of monopolar hemiarthroplasty by the direct anterior approach over a postoperative period up to 2.5 years . Methods A total of 86 patients with displaced femoral neck fractures were included ( mean age of 86.5 years ) . Surviving patients were review ed three months ( retrospectively ) and one to 2.5 years ( prospect ively ) after surgery . One-year mortality was 36 % . Results For all stems , implant positioning with respect to stem alignment , restoration of leg length and femoral offset was correct . Acetabular protrusion was observed in 55 % of the patients one to 2.5 years postoperatively . Subsidence and intraoperative periprosthetic fractures occurred in three patients ( 3 % ) each . All revision stems for postoperative periprosthetic fractures could be implanted using the initial surgical technique without extension of the previous approach . The mean Harris hip score was 85 points at the one to 2.5-year follow-up ; 85 % of the patients were satisfied with their hip and 57 % returned to their preoperative level of mobility . Conclusion Based on these findings , hemiarthroplasty for hip fractures can be performed safely and effectively via the direct anterior approach with good functional outcome and high patient satisfaction Two hundred and twenty-four total hip arthroplasties were performed in 201 patients with use of a femoral component with hydroxyapatite coating of the proximal portion of the stem . The mean duration of follow-up was seventy-one months ( range , fifty-eight to eighty-seven months ) . Of the 224 arthroplasties , 208 ( 93 per cent ; 190 patients ) yielded a good or excellent clinical result . Four patients ( 2 per cent ) reported mild-to-moderate activity-related pain in the thigh , and two ( 1 per cent ) had aseptic loosening . The radiographic findings of progressive new-bone formation ( cancellous condensation and cortical hypertrophy ) throughout the zones adjacent to the middle and distal portions of the stem were evidence of early , extensive proximal fixation of the implant , with distal stress transfer through the implant , which is stiffer than the surrounding bone . Remodeling of the femur began early , was predictable , and progressed throughout the follow-up period . Cortical hypertrophy about the middle and distal portions of the stem occurred predominantly in the mediolateral plane ( in 105 hips [ 47 per cent ] , compared with thirteen hips [ 6 per cent ] in the anteroposterior plane ) , and it was more common in patients who had had poorer bone quality preoperatively . Intramedullary osteolysis was present in one femur ( 0.4 per cent ) at five years ; the osteolytic area was less than five millimeters in its greatest dimension and had not progressed at the time of the six-year follow-up evaluation . This low rate of osteolysis suggests that a circumferential coating of hydroxyapatite may effectively minimize migration of wear debris along the femoral stem . The progressive remodeling of the femur about the middle and distal portions of the stem , as evidence d by cancellous condensation and cortical hypertrophy , has not , to our knowledge , been described previously to this magnitude in association with proximally coated ( porous or hydroxyapatite-coated ) femoral implants Abstract The optimal surgical treatment of displaced proximal humeral fractures is controversial . New implants providing angular stability have been introduced to maintain the intraoperative reduction . In a multi-institutional study , we prospect ively enrolled and followed 152 patients with unilateral displaced and unstable proximal humeral fractures treated either with an ante grade angular and sliding stable proximal interlocking nail or an angular stable plate .  Fractures were classified according to the Neer four-segment classification . Clinical , functional , and radiographic followups were performed 3 , 6 , and 12 months after surgery . Absolute and relative ( to the contralateral shoulder ) Constant-Murley scores were used to assess postoperative shoulder function . Using age , gender , and fracture type , we identified 76 pairs ( 152 patients ) for a matched-pairs analysis . Relative Constant-Murley scores 12 months after treatment with an angular and sliding stable nail and after plate fixation were 81 % and 77 % , respectively . We observed no differences between the two groups . Stabilization of displaced proximal humeral fractures with either an angular stable intramedullary or an extramedullary implant seems suitable with both surgical treatment options . Level of Evidence : Level III , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence Objectives The PROximal Fracture of the Humerus : Evaluation by R and omisation ( PROFHER ) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures . The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics , injury characteristics and the nature of the surgical treatment . Methods A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015 . Data gathered for the 110 patients included patient demographics , injury characteristics , mode of surgical fixation , the grade of operating surgeon and the cost of the surgical implants . Results A majority of the patients were female ( 66 % , 73 of 110 ) . The mean patient age was 62 years ( range 18 to 89 ) . A majority of patients met the inclusion criteria for the PROFHER trial ( 75 % , 83 of 110 ) . Plate fixation was the most common mode of surgery ( 68 % , 75 patients ) , followed by intramedullary fixation ( 12 % , 13 patients ) , reverse shoulder arthroplasty ( 10 % , 11 patients ) and hemiarthroplasty ( 7 % , eight patients ) . The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases ( 91 % , 100 patients ) . Implant costs for plate fixation were significantly less than both hemiarthroplasty ( p < 0.05 ) and reverse shoulder arthroplasty ( p < 0.0001 ) . Implant costs for intramedullary fixation were significantly less than plate fixation ( p < 0.01 ) , hemiarthroplasty ( p < 0.0001 ) and reverse shoulder arthroplasty ( p < 0.0001 ) . Conclusions Our study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may , therefore , have been effectively managed non-operatively . Cite this article : Mr B. J. F. Dean . A review of current surgical practice in the operative treatment of proximal humeral fractures : Does the PROFHER trial demonstrate a need for change ? Bone Joint Res 2016;5:178–184 . DOI : 10.1302/2046 - 3758.55.2000596 BACKGROUND We hypothesized that undergoing surgery as soon as possible reduces early mortality in patients with a proximal femoral fracture . Our aim was to evaluate the association between surgical delay and early mortality in these patients . METHODS We performed a retrospective analysis of prospect ively collected data from the Danish Fracture Data base and the Civil Registration System on patients who were fifty years of age or older and had undergone surgery for a proximal femoral fracture . Femoral head fracture ( classified as OTA/AO 31C per the OTA/AO classification system ) , high-energy trauma , pathological fractures , multiple fractures , and surgeries performed with implants not commonly used were excluded . End points were adjusted odds ratios for thirty-day and ninety-day mortality . RESULTS For the 3517 surgeries included in this study , the median patient age was 82.0 years ( range , fifty-one to 107 years ) , 2458 patients ( 70 % ) were female , and 1720 surgeries ( 49 % ) were performed because of a trochanteric fracture . Within twelve hours , 722 of the surgeries ( 21 % ) had been performed ; within twenty-four hours , 2482 surgeries ( 71 % ) ; within thirty-six hours , 3024 surgeries ( 86 % ) ; within forty-eight hours , 3242 surgeries ( 92 % ) ; and within seventy-two hours , 3353 surgeries ( 95 % ) . Unsupervised surgeons with an education level below that of an attending surgeon performed the surgery in 1807 ( 51 % ) of all cases . The thirty-day mortality was 380 ( 10.8 % ) and the ninety-day mortality was 612 ( 17.4 % ) . The risk of thirty-day mortality increased with a surgical delay of more than twelve hours ( odds ratio , 1.45 ; p = 0.02 ) , more than twenty-four hours ( odds ratio , 1.34 ; p = 0.02 ) , and more than forty-eight hours ( odds ratio , 1.56 ; p = 0.02 ) ; the risk of ninety-day mortality increased with a surgical delay of more than twenty-four hours ( odds ratio , 1.23 ; p = 0.04 ) . An education level of the surgeon below that of an attending surgeon increased the risk of thirty-day mortality ( odds ratio , 1.28 ; p = 0.035 ) and ninety-day mortality ( odds ratio , 1.26 ; p = 0.016 ) . Increasing American Society of Anesthesiologists score and male sex significantly increased both thirty-day and ninety-day mortality . CONCLUSIONS In this study , a surgical delay of more than twelve hours significantly increased the adjusted risk of thirty-day mortality and a surgical delay of more than twenty-four hours significantly increased the adjusted risk of ninety-day mortality . The adjusted risk of both thirty-day and ninety-day mortality increased significantly when the education level of the surgeon was below that of an attending surgeon . The study findings challenge orthopaedic departments to facilitate fast surgical treatment supported by attending orthopaedic surgeons Systematic review s and meta-analyses published in recent years have allowed drafting of evidence -based guidelines for antibiotic prophylaxis in orthopedic and trauma surgery . It is important to recognize the limitations of the recommendations derived from the available body of evidence . Since some of the most relevant r and omized controlled clinical trials were performed more than 20 years ago , it is sometimes difficult to apply the data to today 's clinical practice . In establishing consensus guidelines , it could prove difficult to identify areas for improvement through further research and better compliance . Although recommendations for optimized treatment of orthopedic implant infections are not currently based on first-class evidence , there are very promising new concepts emerging in this field , and we are awaiting more data and decisive conclusions from larger clinical trials The objective of this study comparing the proximal femoral nails Targon PF ( Aesculap , Tuttlingen , Germany ) and Proximal Femoral Nail Antirotation ( PFNA ; Synthes . Oberdorf , Switzerl and ) was to observe the complications and postoperative results following pertrochanteric femoral fracture fixation , with special attention devoted to the dynamic properties of both implants under physiological load in vivo . The survey was design ed as a r and omized , prospect i ve study of 80 patients who had sustained a pertrochanteric femoral fracture ( AO type 31.A2 ) . Postoperative radiological and clinical examinations were conducted over a period of 12 months on 40 respective patients treated with a PFNA or a Targon PF nail .  Average operative time was 66.2 minutes and average fluoroscopy time was 103.6 seconds in the PFNA group , which was significantly lower than in the Targon PF group ( 84.7 minutes and 164.5 seconds , respectively ) . No significant difference was found between the 2 groups in terms of range of motion ( P=.26 ) or Harris Hip Score ( P=.83 ) . The femoral neck components of the Targon PF showed a significantly higher sliding ability ( 14.5 mm ; P=.04 ) than the PFNA ( 11.1 mm).Both implants are suited to treat pertrochanteric femoral fractures and display comparable clinical results . The Targon PF demonstrates better dynamic properties than the PFNA under physiological load in vivo . A disadvantage of the Targon PF , however , is the more complicated surgical technique and the longer operative time Abstract Hemiarthroplasty is the most commonly used treatment for displaced femoral neck fractures in the elderly . There is limited evidence in the literature of improved functional outcome with cemented implants , although serious cement-related complications have been reported . We performed a r and omized , controlled trial in patients 70 years and older comparing a cemented implant ( 112 hips )  with an uncemented , hydroxyapatite-coated implant ( 108 hips ) , both with a bipolar head . The mean Harris hip score showed equivalence between the groups , with 70.9 in the cemented group and 72.1 in the uncemented group after 3 months ( mean difference , 1.2 ) and 78.9 and 79.8 after 12 months ( mean difference , 0.9 ) . In the uncemented group , the mean duration of surgery was 12.4 minutes shorter and the mean intraoperative blood loss was 89 mL less . The Barthel Index and EQ-5D scores did not show any differences between the groups . The rates of complications and mortality were similar between groups . Both arthroplasties may be used with good results after displaced femoral neck fractures . Level of Evidence : Level I , therapeutic study . See the Guidelines for Authors for a complete description of levels of evidence Introduction : In this study , we initiated a prospect i ve , r and omised , clinical trial comparing the AMBI , TGN and PFN operations used for treatment of unstable fractures , for differences in intra-operative use , consolidation , complications and functional outcome . Material s and methods : We have compared the pre- , intra- and post-operating variables of AMBI , TGN and PFN operations that were used for treatment of unstable trochanteric fractures , of 120 patients all above 60 years old diagnosed with extracapsular hip fractures classified as AO Type 31-A2 or Type 31-A3 . Results : According to our results the three methods are comparable in the treatment of unstable trochanteric fractures  of patients above 60 years old . Conclusion : The AMBI remains the gold st and ard for the fractures of trochanteric region . TGN has an easier and faster procedure , facilitates early weight bearing and had minor late complications . An improper use of the PFN system was the reason for the most complications and the longer operation time of the device . PFN is also an accepted minimally invasive implant for unstable proximal femoral fractures but future modification of the implant to avoid Z-effect phenomenon , careful surgical technique and selection of the patients should reduce its high complication rate Purpose Chondromalacia patella is a distinct clinical entity of abnormal softening of the articular cartilage of the patella , which results in chronic retropatellar pain . Its aetiology is still unclear but the process is thought to be a due to trauma to superficial chondrocytes result ing in a proteolytic enzymic breakdown of the matrix . Our aim was to assess the effectiveness of autologous chondrocyte implantation on patients with a proven symptomatic retropatellar lesion who had at least one failed conventional marrow-stimulating therapy . Methods We performed chondrocyte implantation on 48 patients : 25 received  autologous chondrocyte implantation with a type I/III membrane ( ACI-C ) method ( Geistlich Bio material s , Wolhusen , Switzerl and ) , and 23 received the Matrix-assisted Chondrocyte Implantation ( MACI ) technique ( Genzyme , Kastrup , Denmark ) . Results Over a mean follow-up period of 40.3 months , there was a statistically significant improvement in subjective pain scoring using the visual analogue scale ( VAS ) and objective functional scores using the Modified Cincinnati Rating System ( MCS ) in both groups . Conclusions Chondromalacia patellae lesions responded well to chondrocyte implantation . Better results occurred with MACI than with ACI-C. Excellent and good results were achieved in 40 % of ACI-C patients and 57 % of MACI patients , but success of chondrocyte implantation was greater with medial/odd-facet lesions . Given that the MACI procedure is technically easier and less time consuming , we consider it to be useful for treating patients with symptomatic chondral defects secondary to chondromalacia patellae BACKGROUND Controversy exists regarding the use of cement for hemiarthroplasty to treat a displaced subcapital femoral neck fracture in elderly patients . The primary hypothesis of this study was that use of cement would provide better visual analog pain scores following this procedure in an elderly patient population . METHODS Elderly patients ( at least seventy years of age ) without severe cardiopulmonary compromise who presented to one institution with a displaced subcapital femoral neck fracture were offered inclusion in the study . One hundred and sixty patients ( mean age , eighty-five years ) with an acute displaced femoral neck fracture were r and omly allocated to hemiarthroplasty with either a cemented Exeter or an uncemented Zweymüller Alloclassic component . Clinical and radiographic follow-up was performed for two years and the outcomes were recorded by a blinded assessor . The main clinical outcome measures were pain , mortality , mobility , complications , reoperations , and quality of life measured with use of vali date d instruments . RESULTS The mean visual analog pain score at rest did not differ significantly between the groups . The total number of complications was greater in the uncemented group ( sixty-three compared with twenty-eight in the cemented group ) . Subsidence was significantly more common in the uncemented group ( eighteen compared with one in the cemented group ) . Intraoperative or postoperative fracture was also significantly more common in the uncemented group ( eighteen compared with one in the cemented group ) . The mortality rate did not differ significantly between the groups at any time point ( thirty-five deaths in the uncemented group compared with thirty-two in the cemented group at two years ) . The Oxford hip score was significantly poorer in the uncemented group at six weeks ( 38.8 compared with 35.7 in the cemented group ) , and it was also poorer or similar at later follow-up time points although the differences were not significant . There was also a trend toward poorer mobility and greater dependence on walking aids in the cemented group . The postoperative Short Musculoskeletal Function Assessment and Mini-Mental State Examination scores did not differ significantly between the groups . CONCLUSIONS In elderly patients ( seventy years or older ) without severe cardiopulmonary compromise who were treated with hemiarthroplasty for a displaced femoral neck fracture , use of a cemented Exeter implant and use of an uncemented Alloclassic implant provided a comparable outcome with regard to pain . However , implant-related complication rates were significantly lower in the group treated with a cemented implant . Trends toward better function and better mobility in the cemented group were observed . These trends reached significance in particular functional scores at some postoperative time points . LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence Introduction Three dimensional titanium plating system was developed by Farm and in 1995 to meet the requirements of semi rigid fixation with lesser complication . The purpose of this in vivo prospect i ve study was to evaluate and compare the clinical effectiveness of three dimensional and two dimensional Titanium miniplates for open reduction and fixation of m and ibular parasymphysis fracture . Material s and Methods Thirty patients with non-comminuted m and ibular parasymphysis fractures were divided r and omly into two equal groups and were treated with 2 mm 3D and 2D miniplate system respectively . All patients were systematic ally monitored at 1st , 2nd , 3rd , 6th week , 3rd and 6th month postoperatively . The outcome parameters recorded were severity of pain , infection , mobility , occlusion derangement , paresthesia and implant failure . The data so collected was analyzed using independent t test and Chi square test ( α = .05 ) . Results The results showed that one patient in each group had post-operative infection , occlusion derangement and mobility ( p > .05 ) . In Group A , one patient had paresthesia while in Group B , two patients had paresthesia ( p > .05 ) . None of the patients in both the groups had implant failure . There was no statistically significant difference between 3D and 2D miniplate system in all the recorded parameters at all the follow-ups ( p > .05 ) . Conclusion 3D miniplates were found to be better than 2D miniplates in terms of cost , ease of surgery and operative time .  However , 3D miniplates were unfavorable for cases where fracture line was oblique and in close proximity to mental foramen , where they were difficult to adapt and more chances for tooth-root damage and inadvertent injury to the mental nerve due to traction One hundred and thirty-three patients ( 152 hips ) who were an average of thirty-nine years old ( range , sixteen to forty-nine years old ) received a proximally hydroxyapatite-coated femoral prosthesis as part of a total hip arthroplasty and were followed for a minimum of five years ( average , 6.4 years ; range , five to 8.3 years ) or until revision . The average Harris hip score was 47 points ( range , 22 to 77 points ) preoperatively and 93 points ( range , 49 to 100 points ) at the time of the latest clinical evaluation . Two patients who had a well fixed femoral implant had activity-limiting pain in the thigh at the time of the most recent examination . Radiographic changes consistent with bone-remodeling ( cortical hypertrophy and bone condensation ) typically were seen around the mid-part of the shaft of the prosthesis . Forty-eight ( 32 per cent ) of the 148 hips that were included in the radiographic analysis demonstrated a small amount of erosive scalloping in either zone 1 or zone 7 of Gruen et al. , and intramedullary osteolysis was suspected in only one hip . All stems were radiographically osseointegrated according to a modification of the criteria described by Engh et al. Four stems were revised , but none of the revisions were performed because of mechanical failure ( two stems were revised in conjunction with a revision of the cup because of pain ; one , because of an infection ; and one , after a traumatic femoral fracture that occurred six years postoperatively ) . Thus , the rates of aseptic and mechanical failure were both 0 per cent . The combined rate of failure , which included the two stems that were revised because of pain and the two stems that were associated with pain that limited activity , was 2.6 per cent ( four of 152 stems ) . The over-all clinical results associated with hydroxyapatite-coated femoral components were excellent in this group of young patients after intermediate-term follow-up . A review of serial radiographs showed mechanically stable implants with osseous ingrowth , evidence of stress transmission at the middle part of the stem , and minimum endosteal osteolysis Anterior supine intermuscular total hip arthroplasty ( THA ) performed on a fracture table has been increasingly used for primary THA . Accurate cup placement , low incidence of dislocation , shorter hospital stay , and faster return of function are potential benefits of the technique . However , a high complication rate , particularly during a surgeon 's learning curve , has been reported . A retrospective analysis of 61 consecutive anterior supine intermuscular primary THAs with at least 6-month follow-up was performed . All procedures were performed using the anterior supine intermuscular approach with cementless implants under fluoroscopic guidance on a fracture table . Prospect ively collected data were retrospectively review ed to evaluate the early complication rate and radiographic accuracy of implant placement . Five ( 8.2 % ) intraoperative complications were observed : including 3 trochanteric fractures and 2 calcar fractures , 4 of which required cable fixation during the index procedure . One nondisplaced trochanteric fracture was treated conservatively . One patient sustained an injury of the lateral femoral cutaneous nerve . Postoperative complications included 1 anterior dislocation , 1 infected superficial hematoma , 1 stem subsidence , and 1 loose stem , with the latter 2 presenting as increasing thigh pain postoperatively and requiring stem revision . The overall complication rate was 16.4 % ( 10/61 ) . Overall , 3 patients ( 4 hips ; 6.5 % ) required reoperation . No femoral or sciatic nerve injuries occurred , and no patient was diagnosed with venous thromboembolism . All intraoperative fractures occurred during the first 32 cases , and none during the last 29 cases . A potentially high incidence of complications with the anterior supine intermuscular THA exists during a surgeon 's learning curve in an academic setting AIMS Oxidised zirconium was introduced as a material for femoral components in total knee arthroplasty ( TKA ) as an attempt to reduce polyethylene wear . However , the long-term survival of this component is not known . METHODS We performed a retrospective review of a prospect ively collected data base to assess the ten year survival and clinical and radiological outcomes of an oxidised zirconium total knee arthroplasty with the Genesis II prosthesis . The Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , Knee Injury and Osteoarthritis Outcome Score ( KOOS ) and a patient satisfaction scale were used to assess outcome . RESULTS A total of 303 consecutive TKAs were performed in 278 patients with a mean age of 68 years ( 45 to 89 ) . The rate of survival ten years post-operatively as assessed using Kaplan-Meier analysis was 97 % ( 95 % confidence interval 94 to 99 ) with revision for any reason as the endpoint . There were no revisions for loosening , osteolysis or failure of the implant . There was a significant improvement in all components of the WOMAC score at final follow-up ( p < 0.001 ) . The mean individual components of the KOOS score for symptoms ( 82.4 points ; 36 to 100 ) , pain ( 87.5 points ; 6 to 100 ) , activities of daily life ( 84.9 points ; 15 to 100 ) and quality of life ( 71.4 points ; 6 to 100 ) were all at higher end of the scale . DISCUSSION This study provides further supportive evidence that the oxidised zirconium TKA gives comparable rates of survival with other implants and excellent functional outcomes ten years post-operatively . TAKE HOME MESSAGE Total knee arthroplasty with an oxidised zirconium femoral component gives comparable long-term rates of survival and functional outcomes with conventional implants Abstract Background Surgical treatment for displaced proximal humeral fractures is widely used . However , there are very few r and omized controlled studies comparing surgical treatment to conservative treatment , and the evidence is debated . The aim of this study was to describe patients with displaced proximal humeral fractures in a 2-years extension of a r and omized controlled trial , their functional outcome and quality of life .  Material s and methods Patients from a single-center r and omized controlled study of fifty patients aged 60 or above with displaced proximal humeral fracture ( AO/OTA group B2 or C2 ) were r and omized to surgical or conservative treatment . Surgery was performed with an angular stable implant . The main outcome was Constant score at 2-year follow-up . Secondary outcomes were an ASES self- assessment form , the 15D quality of life assessment and radiographs at 2 years . Results A marked improvement of shoulder function and health-related quality of life for both surgically and conservatively treated patients occurs between 6 and 12 months . Almost no change was observed between 1 and 2 year . There were no significant differences between the two treatments at 2-year follow-up . Conclusions In this r and omized controlled trial , surgical treatment proved no better results than conservative treatment for patients with displaced proximal humeral fracture at 2-year follow-up BACKGROUND Patients with proximal femoral fracture ( PFF ) are at high risk of postoperative complications . Goal -directed haemodynamic treatment ( GDHT ) in other high-risk surgical patients reduces postoperative complications . We aim ed to compare effects of GDHT and routine fluid treatment ( RFT ) on postoperative outcomes after PFF surgery . METHODS PFF patients ( ≥70 yr ) were enrolled in this single-centre , open , r and omized , controlled , parallel-group superiority trial with concealed allocation using computer-generated r and omization . TREATMENTS ( i ) GDHT to attain oxygen delivery index > 600 ml min(-1 ) m(-2 ) using fluids and dobutamine and ( ii ) a protocol -guided RFT .  After 150 enrolled patients , the trial was stopped due to slow recruitment . The short-term primary outcome measure was the relative risk ( RR ) of postoperative complications ; secondary measures were ( i ) administered fluid levels , ( ii ) vasopressor requirements , and ( iii ) haemodynamic responses . RESULTS For the GDHT group , 74 and for the RFT group 75 patients were design ated . The RR of postoperative complications ( GDHT vs RFT ) was 0.79 ( 95 % confidence interval 0.54 - 1.16 ) ; the volumes of i.v . fluids decreased ( 1078 vs 1440 ml , P=0.01 ) ; fewer patients required treatment of hypotension ( 18.5 % vs 75 % , P<0.005 ) ; there were more patients with increased oxygen delivery at the end of operation ( 28 % vs 8 % , P=0.04 ) , but the haemodynamic goal was achieved in only 27 % of patients in the GDHT group . CONCLUSIONS The magnitude of risk reduction of postoperative complications is clinical ly relevant , but the trial was underpowered and the null hypothesis can not be rejected Purpose There is no consensus about the best option of internal fixation for unstable intertrochanteric fractures . The aim of the present study was to compare proximal femoral nail ( PFN ) with contralateral reverse distal femoral locking compression plate ( reverse-DFLCP ) in the management of unstable intertrochanteric fractures with compromised lateral wall . Method In a r and omized controlled study , from November 2011 to October 2012 , 40 patients with unstable intertrochanteric fractures with compromised lateral wall ( AO 31A 2.2 to 3.3 ) had osteo synthesis by PFN ( n = 20 ) or reverse-DFLCP ( n = 20 ) . Intra-operative variables compared were duration of surgery , blood loss during surgery , fluoroscopy time and surgeons perception of the surgery . Patients were followed up clinical ly for a minimum of one year . Functional outcome was assessed by Parker Palmer mobility score ( PPMS ) , Harris hip score ( HHS ) , and Short Form-12 . Failure was defined as any condition which would necessitate revision surgery with change of implant . Results Duration of surgery ( p = 0.022 ) , blood loss during surgery ( p = 0.008 ) and fluoroscopy time ( p = 0.0001 ) were significantly less in the PFN group than in the reverse-DFLCP group . No significant difference was found in type of reduction , difficulty in reduction and surgeon ’s perception of surgery . The PFN group had better functional outcome than the reverse-DFLCP group . HHS for the PFN group was 81.53 ± 13.21 and for the reverse-DFLCP group it was 68.43 ± 14.36 ( p = 0.018 ) . SF-12 physical ( p = 0.002 ) and mental component ( p = 0.007 ) scores in the PFN group was significantly better than in the reverse-DFLCP group . There was one failure in the PFN group as compared to six in the reverse-DFLCP group ( p = 0.036 ) . Conclusion Due to favourable intra-operative variables , better functional outcome and lower failure rates , we conclude that PFN is a better implant than reverse-DFLCP for intertrochanteric fractures with compromised lateral wall Background Due to its collarless , double-tapered polished design , the Exeter femoral stem is known to migrate distally in the first 5 years after implantation . However , its long-term migration pattern has not been investigated . Patients and methods 39 consecutive patients ( 41 total hip arthroplasties ) received a cemented Exeter stem and had prospect i ve clinical and RSA follow-up . Patients were evaluated postoperatively at 6 , 12 , 26 , and 52 weeks , and annually thereafter . Short-term results have been reported . In this study , the mean length of follow-up was 9.4 years ( SD 3.2 years ) . No patients were lost to follow-up . 15 patients died during follow-up . Results No stems were revised . In 4 stems , fractures of the cement mantle were noted within the first 3 postoperative years . In 3 stems , this result ed in a complete circumferential cement mantle discontinuity . For the 37 well-performing stems , continuous but small migration was measured between 2 and 12 years of follow-up . Continued subsidence of 0.08 mm/year ( 95 % CI : 0.05–0.12 , p < 0.001 ) was seen in combination with continued rotation in retroversion of 0.07 ° /year ( 95 % CI : 0.02–0.12 , p = 0.01 ) . At 10 years of follow-up , mean subsidence was 2.1 ( SD 1.2 ) mm and mean retroversion was 1.8 ° ( SD 2.0 ) . Two-thirds of this occurred during the first 2 postoperative years . In the 3 stems with a complete circumferential cement fracture , a sudden and disproportionately high increase in subsidence was measured in the time period of occurrence . Interpretation The Exeter femoral stem continues to migrate during the first decade after implantation . Absolute stability is not required for good long-term survival if this is compatible with the design of the implant The cortical bone mineral density ( BMD ) , bone volume , bone mass and muscle volume of the thigh , and the BMD of the distal femur and proximal tibia were measured quantified by quantitative computed tomography ( QCT ) after an operation for a displaced femoral neck fracture . Twenty patients were r and omized to osteo synthesis or total hip arthroplasty ( THA ) .  Both legs were scanned after 18 months , and the operated side was compared with the healthy side . Clinical assessment was performed with a Harris hip score .  A reference group of 9 patients , who had undergone THA because of arthrosis , was chosen . In the fracture patients , we found a 9 % decrease in bone mass and muscle volume of the middle femur . The BMD of the distal femur and proximal tibia showed a more marked osteopenia . There was no difference in these parameters between the two groups . In the reference group of operated arthrosis patients , we did not find any differences between sides postoperatively . After the operation , the fracture patients had a lower Harris score than the arthrosis patients , and this was most pronounced among those who had undergone osteo synthesis . The finding of a marked osteopenia after a femoral neck fracture , irrespective of treatment , but no bone loss after THA because of arthrosis , implies that patients with a femoral neck fracture are more sensitive to osteopenia , and that the bone loss is not proportional to the operative trauma . caused by the disuse and the posttraumatic effect on the bone caused by the operation . Also , the magnitude of the operative trauma may play a role in the development of the osteopenia . Thus , a displaced femoral neck fracture , treated with osteo synthesis or total hip arthroplasty ( THA ) , offers a possibility to distinguish between the osteopenia caused by the fracture and the role of the operation , since the degree of the operative trauma is different . The aim of this study was to investigate whether or not the bone loss after a displaced femoral neck fracture depends on the mode of treatment PURPOSE The possibility of expediting dental implant therapy by early or immediate loading protocol s requires long-term clinical investigation . The aim of this prospect i ve cohort trial was to determine the 3-year implant success rate and prosthesis complications associated with functional loading 3 weeks after 1-stage placement of Astra Tech single-tooth implants replacing maxillary anterior teeth . A secondary objective was to determine peri-implant tissue responses at these implants . MATERIAL S AND METHODS The peri-implant bone and mucosal conditions of 43 implants in 39 subjects were radiographically and clinical ly measured 3 years after implant placement . RESULTS Of the 48 patients originally treated , 39 patients and 43 implants were examined at the 3-year time point . Three of 54 implants failed within the first year . No additional failures were recorded since the 12-month reporting period . Peri-implant bone levels were stable for the 3-year period following implant placement . The change in marginal bone levels after 3 years was 0.42 + /- 0.59 mm . Papilla growth was measured at 1 and 3 years ( 0.61 + /- 0.95 mm and 0.74 + /- 0.79 mm , respectively ) . The buccal peri-implant tissue dimensions at the gingival zenith also increased at 1 and 3 years ( 0.34 + /- 0.94 mm and 0.51 + /- 1.42 mm , respectively ) . No abutment screw loosening or fracture occurred . DISCUSSION AND CONCLUSIONS Early loading of endosseous dental implants placed in healed ridges offers select benefits to clinicians and their patients PURPOSE The literature reports that flapless compared with traditional implant surgery can be associated with several advantages , including the maintenance of peri-implant hard tissues . This study investigated vertical bone resorption during long-term follow-up after implant placement with flapless versus traditional surgery . MATERIAL AND METHODS In this prospect i ve , r and omized controlled clinical trial , 40 patients underwent implant placement at the Maxillofacial Department Surgery of the Istituto Stomatologico Italiano Hospital in Milan , Italy . Patients were r and omly assigned to the control or experimental group . The control group had implants placed with open flap surgery ( traditional surgery ) , whereas the experimental group had implants placed with flapless surgery . The distance between the first implant thread and the marginal crestal bone level was measured at the basal , loading , and long-term control points . The basal recording was performed just after implant placement . The loading measurement was recorded at the time of implant loading , after 2 months of healing for the lower jaw and after 3 months of healing for the upper jaw , and the long-term control record was registered 36 months after implant placement . Statistical analysis was performed using mean values and st and ard deviations based on bone resorption in the 2 groups . To detect statistical differences , the Student t test was applied . Differences were considered significant if P values were less than .05 . RESULTS The control group ( open flap surgery ) was comprised of 19 patients , and the experimental group ( flapless surgery ) was comprised of 21 patients . No statistical differences were found in peri-implant bone resorption between the 2 groups at the basal , implant loading , and 3-year control recordings . CONCLUSION According to this study , the approach to implant surgery does not seem to influence peri-implant bone resorption in humans , at least for the period measured in this study Introduction The direct anterior approach ( DAA ) is generally accepted method for minimal invasive arthroplasty of the hip . As good results for total hip arthroplasty are already published , there is a lack of evidence for the implantation of bipolar hip hemiarthroplasty ( BHH ) in elderly patients with osteoporosis after femoral neck fracture . Material s and methods For hip arthroplasty using a direct anterior approach ( DAA ) in elderly patients with femoral neck fractures , a number of modifications of the original technique are being described . The modified DAA considers in particular the co-morbidity and the bone quality of the geriatric patient population . A consecutive series of 16 hemiarthroplasties using this technique is presented . In all 16 cases , the BHH was implanted in modified DAA technique . Mobility measured by 4-item Barthel Index , pain via visual analogue scale ( VAS ) , duration of surgery , external length of incision and blood loss were evaluated . Results There was no major operative complication during the procedures . The pain level decreased from 7 ( preoperatively ) to 0 at postoperative day 40 . The Barthel Index increased from 5 at first postoperative day to 40 at day 40 . Early postoperative mobilisation is efficiently accelerated . Mean operating time was 71 min ; the medium skin incision length was 8 cm . The mean haemoglobin level decreased from 118 g/dl preoperatively to 101 g/dl at first postoperative day . Conclusion The described modifications of the DAA help to implant a BHH gently in elderly patients with increasing risk of complications like iatrogenic fractures , wound or prosthesis infections and haematoma . This will hopefully lead to a faster rehabilitation and lower mortality rate for patients with femoral neck fractures in the future
The clinical evidence behind the current implants used for proximal femoral fractures is weak considering the number of implants used worldwide .
Sporadic evaluation is not sufficient to identify long term problems .
INTRODUCTION Evaluation of the long-term performance of  implants used in trauma surgery relies on post-marked clinical studies since no registry based implant assessment exists .
The purpose of this study was to evaluate the evidence of performance of implants  currently used for treating proximal femoral fractures ( PFF ) in Denmark .