Aims. In UK there are around 76,000 hip fractures occur each year 10% to 15% of which are undisplaced intracapsular. There is considerable debate whether internal fixation is the most appropriate treatment for undisplaced fractures in older patients. This study describes cannulated hip screws survivorship analysis for patients aged ≥ 60 years with undisplaced intra-capsular fractures. Methods. This was a retrospective cohort study of consecutive patients aged ≥ 60 years who had cannulated screws fixation for Garden I and II fractures in a teaching hospital between March 2013 and March 2016. The primary outcome was further same-side hip surgery. Descriptive statistics were used and Kaplan-Meier estimates calculated for implant survival. Results. A total of 114 operations were performed on 112 patients with a mean age of 80.2 years (SD 8.9). The 30-day and one-year mortality were 1% (n = 1) and 13% (n = 15), respectively. Median follow-up was 6.6 years (interquartile range 6.0 to 7.3). Kaplan-Meier estimates showed a survivorship of 95% at one year and 90% at five years (95% confidence interval 84% to 95%) for cannulated screws. Nine patients underwent further hip surgery: four revision to total hip arthroplasty, one revision to hemiarthroplasty, three removals of screws, and one haematoma washout. Posterior tilt was assessable in 106 patients; subsequent surgery was required in two of the six patients identified with a posterior angle > 20° (p = 0.035 vs angle < 20°). Of the 100 patients with angle < 20°, five-year survivorship was 91%, with seven patients requiring further surgery. Conclusion. This study of cannulated hip screw fixation for undisplaced fractures in patients aged ≥ 60 years reveals a construct survivorship without further operation of 90% at five years. Cannulated screws can be considered a safe reliable treatment option for Garden I and II fractures. Caution should be taken if posterior tilt angle on lateral view exceeds 20°, due to a higher failure rate and reoperation, and considered for similar management to Garden III and IV injuries. Cite this article: Bone Jt Open 2022;3(3):182–188

Debate continues about the best treatment for patients over 65 years with non-displaced subcapital hip fractures: internal fixation (IF) or hemiarthroplasty (HA). Surgical aggression, mortality, complications and recovery of walking ability after 1year have been compared between both treatments.

Match-paired comparison of 2 retrospective cohorts. 220 patients with IF vs 220 receiving a cemented bipolar HA. Matching by age (82.6±7.16 years (65–99)), sex (74.5% women), year of intervention (2013–2021) and ASA scale (24.2% ASA II, 55.8% III, 20.0% IV).

Age (p=0.172), sex (p=0.912), year of intervention (p=0.638) and ASA scale (p=0.726) showed no differences.

Surgical aggression smaller in IF: Surgical time (p< 0,00001), haemoglobin/haematocrit loss (p <0,00001), need for transfusion (p<0,00008), in-hospital stay (p<0,00001).

Mortality: higher in-hospital for hemiarthroplasties (12 deaths (5.5%) vs 1 (0.5%) (p=0.004) (RR=12, 1.5–91.5)). But no significant differences in 1-month (13 hemiarthroplasties, 6%, vs 9 osteosynthesis, 4.1%) and 1-year mortality (33 hemiarthroplasties, 15%, vs 35, 16%).

Medical complications: no differences in urinary/respiratory infections, heart failure, ictus, myocardial infarction, digestive bleeding, pressure sores or pulmonary embolus (p=0.055).

Surgical complications: no significant differences. HA: 6 intraoperative (2,7%) and 5 postoperative periprosthetic fractures (2,3%), 5 infections (2,3%), 10 dislocations (4,5%), 3 neurovascular injuries. IF: 10 acute fixation failures (4,5%), 2 infections (0,9%), 9 non-unions (4,1%), 16 ischemic necrosis (7,3%).

Functional results: no significant differences; 12 patients in each group (5,5%) never walked again (p=1), 110 HA (50%) and 100 IF (45.5%) suffered worsening of previous walking ability (p=0.575), 98 HA (44%) and 108 IF patients (49%) returned to pre-fracture walking ability (p=0.339).

Fixation with cannulated screws may be a better option for non-displaced femoral neck fractures because recovery of walking ability and complications are similar, while surgical aggression and in-hospital mortality are lower.

For the management of displaced patellar fractures, surgical fixation using cannulated screws along with anterior tension band wiring is getting popular. Clinical and biomechanical studies have reported that using cannulated screws and a wire instead of the modified tension band with Kirschner wires improves the stability of fractured patellae. However, the biomechanical effect of screw proximity on the fixed construction remains unclear. The aim of this study was to evaluate the mechanical behaviors of the fractured patella fixed with two cannulated screws and tension band at different depths of the patella using finite element method.

A patella model with simple transverse fracture [AO 34-C1] was developed; the surgical fixation consisted of two 4.0-mm parallel partial-threaded cannulated screws with a figure-of-eight anterior tension band wiring using a 1.25-mm stainless steel cable. Two different locations, including the screws 5-mm and 10-mm away from the leading edge of the patella, were used. A tension force of 850 N was applied on the patellar apexes at two loading angles (45° and 0° [parallel] to the long axis) to simulate different loading conditions while knee ambulation. The proximal side (base) of the patella was fixed, and the inferior articular surface was defined as a compression-only support in ANSYS to simulate the support from distal femur condyles. Compression-only support enables the articular surfaces of the present patella to only bear compression and no tension forces.

Under different loading conditions, the fixed fractured patella yielded higher stability during 0° loading of tension force than during 45° loading. When the screws were parallel placed at the depth of 5 mm away from the patellar surface, the deformation of patellar fragment and maximum gap opening at the fracture site were smaller than those obtained by screws placed at the depth of 10 mm away from the patellar surface. Compared to the superficial screw placement, the deeper placement (10 mm) increased the maximum gap opening at the fracture site by 1.56 times under 45° loading, and 1.58 times under 0° loading. The load on the tension band wire of the 10-mm screw placement was 3.12 times (from 230 to 717 N) higher than that of the 5-mm placement. Under the wire, the contact pressure on the patellar surface was higher with the 10-mm screw placement than the 5-mm screw placement. The peak bone contact pressures with the 10-mm placement were 7.7 times (99.5 to 764 MPa) higher.

This is the first numerical study to examine the biomechanical effects of different screw locations on the fixation of a fractured patella using screws and tension band. Based on a higher stability and lower cable tension obtained by the superficial screws placement, the authors recommended the superficial screw placement (5 mm below the leading edge of the patella) rather than the deep screws while fixing the transverse patellar fracture with cannulated screws and cable.

Background: Fracture of the scaphoid bone is the most common fracture of the carpus and frequently diagnosis is delayed. The unique anatomy & blood supply of the scaphoid itself predisposes to delayed union or non-union.

The Synthes scaphoid screw is a cannulated headed screw, which provides superior compression compared with some other devices used to internally fix scaphoid non-unions.

Aim: To conduct a retrospective study looking at union rate, time to union and complications and correlating the outcome of treatment against the delay between injury and surgery and location of the fracture within the bone.

Methods: 36 patients with scaphoid non-union (30 waist & 6 proximal pole) treated by a single surgeon with the cannulated Synthes screw & corticocancellous bone graft were reviewed retrospectively.

Results: We achieved 78% overall union rate. Those patients operated within 6 months of injury achieved 100% union rate. Of the patients with persistent non-union after surgery, half reported no pain and increased movement in the wrist. The failure rate was high in patients whose injury was more than 5 years old, and in proximal pole non-unions.

Conclusion: Our study demonstrates that cannulated screw fixation with bone grafting has high success rate for delayed union of scaphoid waist fractures and scaphoid waist nonunions present for less than 5 years. Patients who present more than 5 years after injury or with proximal pole nonunions have a high chance of persistent nonunion, but can symptomatically improve.

INTRODUCTION – Tuberosity fractures of the calcaneum are rare injuries. The traditional operative treatment involves open reduction and internal fixation with a tension band wire construct. We have developed a new technique of fixing these fractures with internal fixation using cannulated screws and a figure of eight wire. This paper describes the new technique outlining its advantages and compares the 2 methods of fixation biomechanically to determine their properties with respect to fracture fixation.

METHOD – 20 sections of bovine bone were taken to act as an experimental model for the calcaneum. They were osteotomised to create the posterior process fracture model. 10 were fixed using a traditional tension band wire construct and 10 were fixed using the cannulated screw and wire construct. Each construct was subjected to biomechanical testing to identify the stiffness, energy to failure and load to failure.

RESULTS – During loading the cannulated screw and wire constructs showed a significant increase in stiffness and energy to failure compared to the tension band wire constructs

CONCLUSION – The increased stability of the cannulated screw construct demonstrated by the testing offers biomechanical benefit over the traditional tension band wire construct. This, as well as the improved technical aspects of the cannulated screw fixation, may be beneficial for clinical use.

Inter-phalangeal (IP) joint fusion of lesser toes has been quite a commonly done procedure using Kirchner wires (K-wire). Infection from the K-wire site has been significant complication. We present a retrospective study of 21 toes of arthrodesis of IP joints of lesser toes using a cannulated screw.

The indications were either claw toe or a hammer toe. All the cases that were done from February 2006 to June 2008 were included. There were 21 toes in 15 patients at an average age of 69 years (range 54 – 80). There were 20 females and only one male. The distribution of second, third and fourth toes were 12, 6 and 3 respectively. Nine toes were right sided and 12 were left sided. They were followed for an average of 14 months (range 2–30).

There was one case of superficial cellulitis (4.8%) which has responded well to antibiotic therapy. There were two cases where the prominent screws had to be removed at 4 and 5 months post-operative period. Good arthrodesis has been achieved by this time.

Clinical arthrodesis was achieved at 4.5 months (range 3–7) and radiological arthrodesis was achieved at 5.2 months (range 4 – 9). All have been discharged at the time of this study.

Good correction of deformities with well healed arthrodesis was achieved. Most patients reported pain free toes. We have found this technique to be very useful alternative with good results and less complications.

Purpose: To determine if femoral neck shortening after cannulated screw fixation has a negative impact on patients’ quality of life.

Methods: Restrospective Observational Study. Database Review of 3 hospitals 1998–2003. Criteria: Inclusion: successfully treated hip# with cannulated screws. Exclusion:non union, malunion, implant failure, contralateral arthroplasty, death, dementia, illiterate, acute illness. Pts were evaluated with radiographic and outcome studies. Contralateral hip was the control for assessing radiographic parameters.

Results: 56 eligible, 13 met criteria (12 non displaced, 1 displaced). Average(avg)follow up:31 months. 8 pts had femoral neck shortening greater than 5mm, avg abductor moment shortening of 8+/− 2.7mm, avg femoral neck shortening of 6+/−1.9mm in shortened pts. Significant differences (sf-36 subscales)between shortened and non shortened pts. Role physical 53 vs 95 (p=0.04) and physical function 50 vs 91 (p=0.01).

Conclusions: Femoral neck shortening after fixation is associated with a negative effect impact on quality of life.

Hip fracture is a common serious injury in the elderly. Between 1982 and 1998 the number of hip fractures reported annually in Scotland in patients over 55 years rose from 4,000 to 5,700. The optimum method of treatment for the various fracture types remains in contention.

We compare outcome measures between displaced, intracapsular fractures in patients over 70 years fixed with cannulated screws and sliding hip screw with side plate.

Between 1998 and 2005 a total of 30,482 patients were reviewed by the Scottish Hip Fracture Audit (SHFA). Of these 15,823(53.3% of the total) had sustained intracapsular fractures. 13,587 of these occurred in patients aged 70 or over. Of these 2,428 had undisplaced and 11,159 displaced fractures. Chi test statistical analysis compare outcome measures in this group of displaced intracapsular fractures with respect to aspects of early failure.

534(3.9%) of patients were treated conservatively. 509 (4.7%) fractures were fixed using cannulated screws and 499 (4.6%) using a sliding hip screw. Readmission within 120 days for any cause occurred in 62 patients(14.1%) treated with cannulated screw fixation and in 63 patients(15.7%) for those treated with a sliding hip screw(P=0.509). Of these 36 patients(8.2%) in the former and 23 patients(5.7%) in the latter group were readmitted for complications related to hip fracture(P=0.033). Mortality within this period included 69 patients(13.5%) in the CS and 98(19.6%) in the SHS group. In terms of re-operation within 120 days of the original admission, 53 patients(10.6%) receiving cannulated screws compared to 24 patients(4.8%) treated with a sliding hip screw requiring further surgery(P=0.0006). The fracture was seen to displace in 12(22.6%) patients originally treated with cannulated screws compared to 6 patients(25%) treated with sliding hip screw(P=0.156). More significantly the fixation device was seen to have migrated in 24(45.3%) of the cannulated screw as compared to 7(29.2%) patients in the sliding hip screw group(P=0.002). Periprosthetic fractures were recorded in 4(7.5%) of the former and 3(12.5%) in the latter group(P=0.708). Wound infection was higher in the SHS group(2 patients) as compared to the screw fixation group(1 patient)(P=0.565).

Statistical analysis demonstrates a dramatic difference exists between these 2 fixation types in terms of re-operation within 120 days of the original admission for which published literature has previously only recorded biomechanical, in vitro comparisons.

Data regarding specific implant factors such as number of screws, position, configuration, starting point, thread length and use of washers in cannulated screws, and position, tapping, supplementary screw and compression screw in sliding hip screws was not recorded and may be considered to bias our results.

Single screw fixation for the management of slipped upper femoral epiphysis (SUFE) was introduced in 1984 and has been reported to have less chondrolysis and avascular necrosis (AVN) than previous methods using multiple pin fixation or osteotomy (Ward 1992). Two groups of patients were investigated. The first group of 55 hips (44 patients) were treated over a 27 year period (1963–1989). Forty four hips were treated with multiple pins and 11 hips with primary intra- or extracapsular osteotomy. These patients were followed up for an average of 8 years (3–27yrs). The second group of 88 hips (69 patients) were treated over a 6 year period (1999–2004). All were treated with single screw fixation and followed up for at least one year.

The duration and severity of slip were found to be similar for both groups. In the second group 16 hips (20%) were unstable (unable to walk even with crutches). Instability had not been coined as a term in the first group. All serial radiographs were retrospectively reviewed for AVN and chondrolysis and correlated with clinical findings. In the first group AVN occurred in 8 hips (14.5%). Five (9%) were due to osteotomies, two (3.5%) due to manipulation and one (2%) due to pinning in the superior quadrant. Chondrolysis occurred in 14 hips (25%); eight (14%) at presentation and six (11%) due to persistent pin penetration. In the second group AVN occurred in two hips (2%). Both were unstable. Two of 16 unstable hips (12.5%) developed AVN. Chondrolysis occurred in 6 hips (7%); four (4.5%) at presentation and 2 (2.5%) due to persistent pin penetration.

The authors conclude that single screw fixation is a safer technique than multiple pin fixation or osteotomy. AVN only occurred in unstable slips. Chondrolysis due to pin penetration is significantly reduced.

Purpose of Study:

In situ fixation with cannulated screws, is the most common surgical management of Slipped Capital Femoral Epiphysis. Surgeons are wary of the consequences to the epiphysis with any manipulation of the hip. The purpose of this study, was to evaluate the use of a single cannulated screw, inserted with imaging done in the standard AP position, and gentle positioning for a frog lateral X-ray, and the risk of slip progression.

Introduction: Fluoroscopy-based navigation systems enables surgeons to place implants with a simultaneous multi-planar monitoring. Percutaneous fixation of femoral neck fractures is an example of the growing usage of these systems in orthopedic trauma surgery. Growing evidence suggests that the accuracy of screw placement might affect the fracture outcome.

Methods: Between 2/2001 and 8/2005, 80 patients underwent internal fixation of femoral neck fractures using computerized navigation system. Three cannulated screws were implanted in an inverted triangle formation. The average patient’s age was 62±20 years (range 11–88), and 12 patients were under the age of 40 years. 53 patients were female, 27 male. 68 patients sustained the fracture due to a simple fall, 4 fell from high ground, 3-bicycle injuries, 2 due to motor vehicle accidents, and 3 patients suffered from insufficiency fractures with no trauma. The data includes results for both undisplaced fractures and fully displaced fractures which underwent closed reduction.

Results: The average length of hospital stay was 6.3±4 days (range 1–19). The average operating room time was 82±22 minutes (range 30–135), this including the preparation of the patient and instrumentation. Complications included one case of infection which necessitated long term antibiotic treatment, four patients requiring hip arthroplasty due to avascular necrosis of the femoral head, and one patient who underwent hip arthroplasty due to osteoarthritis. The total failure rate is 6%.

Conclusions: Computerized navigation for the internal fixation of subcapital femoral neck fractures allows improved screw positioning, which may reduce fracture complications, and provides reduced radiation to both the surgeon and the patient.

Cannulated hip screws are frequently used in the management of hip fractures. There have been concerns over the failure rate of the technique and the outcomes of those that subsequently require conversion to total hip replacement (THR). This study utilised a database of over 600 cannulated hip screw (CHS) fixations performed over a 14-year period and followed up for a minimum of one year (1-14). We identified 57 cases where a conversion to THR took place (40 females, 17 males, mean age: 71.2 years). Patient demographics, original mechanism of injury, fracture classification, reason for fixation failure, time until arthroplasty, implant type and post-arthroplasty complications were recorded. Clinical outcomes were measured using the Oxford Hip Score. The failure rate of cannulated screw treatment was 9.4% and the mean time from initial fixation to arthroplasty was 15.4 (16.5) months. Thirty six fractures were initially undisplaced and 21 were displaced. As one might expect the displaced cases tended to be younger but this didn't reach statistical significance [66.5(14.3) vs 72.7(13.1), p=0.1]. The commonest causes of failure were non-union (25 cases, 44%) and avascular necrosis (17 cases, 30%). Complications after THR consisted of one leg length discrepancy and one peri-prosthetic fracture. The mean Oxford score pre-arthroplasty was 12.2 (8.4), improving to 38.4 (11.1) at one-year. Although the pre op Oxford scores tended to be lower in patients with undisplaced fractures and higher ASA scores, the improvement was the same whatever the pre-op situation. The one-year Oxford score and the improvement in score are comparable to those seen in the literature for THR in general. In conclusion, CHS has a high success rate and where salvage arthroplasty is required it can provide good clinical outcomes with low complication rates

Aim. There is controversy about the need of remove implants removal in pediatric patients. One of the potential disadvantages of not doing it is potential infection. Since the orthopaedic implants (O.I.) are handled under an aseptic protocol, the expected results are the absence of germs in those devices. However, the risk of contamination and potential infection cannot be ruled out. For these reason we wanted to determinate the percentage of colonization in the O.I. removed from pediatric patients of the H.G.G.B. in Concepción, Chile. Method. Prospective observational study. The population consisted of 137 patients with previous osteosynthesis. 10 patients were excluded who had extruded material. The sample consisted of 127 patients in whom 331 implants were removed. The analysis unit was the cultures of the O.I. removed with aseptic techniques. The data was analyzed by descriptive statistics. Results. 19% (63) of the removed material was colonized;. The percentage of positive cultures according to type of material in decreasing order was: Cannulated screws (22.9%), Kirschner wires (20.3%), TENS (7.4%) and plate (6.7%). The first and third are titanium materials, while the second and fourth are made of steel. The relationship according to type of limb was: 20.5% of the O.I. of the lower extremity and 15.2% of the upper limb. The relationship according to type of patient was: 24% in elective patients and 13.8% in emergency patients. The main germs grown in decreasing order were: Staphylococcus epidermidis (69.1%), S. Haemolitycus (9.1%), S. Hominis (7.3%), S. Capiti (5.5%). Conclusions. The colonization of O.I. removed from pediatric patients is higher than the infections reported in adults. It is striking that colonized material from elective patients is superior to emergency patients. It also highlights that titanium has almost the same colonization level than steel. These results provide evidence to consider the removal of O.I. from pediatric patients, particularly in patients with lower extremity devices

Cannulated screw is commonly used in the fixation of proximal femoral neck fractures. In the literature, several configurations had been proposed for best mechanical support with clinical experiences or biomechanical tests. Although screws in triangle configuration contribute certain fixation stability, but sometimes the surgeons made their own choices have to conduct another fixation pattern for some factors such as fracture type, economic issues, and so on. Therefore the aim of this study is to analyze the mechanical responses of a fractured femur fixed with screws in different configurations, screw materials and screw diameters with finite element method, trying to find the most stable construct. A solid femur model was built from the CT images of a standard saw bone. Three fracture types of the femoral neck were created according to Pauwel's classification (30?, 50?, 70?) by CAD software. The models of implanted screws were built according to a commercial cannulated screw (Stryker Osteosynthesis, Schoenkirchen/Kiel, Germany) with diameter 6.5mm and 4.5mm by CAD software, too. Three fixation configurations were analyzed in this study, including triangle with superior single screw with titanium diameter 6.5mm, triangle with inferior single screw with diameter 6.5mm and diamond with four stainless screw diameter 4.5mm (fig.1). Totally there were nine models constructed in this study, and all of them were then imported into ANSYS WORKBENCH v14 (Swanson Analysis, Houston, PA, USA) to mesh and further analysis. 700N vertical downward force was applied on the femur head and the distal end of femur shaft was totally fixed. The triangle fixation with superior single screw resulted in a best stability, but the fracture fixed with screws in a diamond configuration has least fracture gap. The difference of the maximum displacement of the femur head with Pauwel's classification 70?between triangle fixation with superior single screw and diamond configuration is only 0.03mm (1.72–1.69 mm). In most unstable femoral neck fracture [Pauwel's classification 70], the maximum gap distance is 0.59mm under the diamond configuration, while it is 0.63mm as the fracture fixed with a triangle configuration. Therefore, this study suggests that four 4.5mm stainless screws in a diamond configuration is an alternative for proximal femur fracture once 6.5mm titanium screws are not available

Proximal femoral fractures remain the most common reason for admission to hospital following orthopaedic injury, with an annual cost of £1.7 billion to the National Health Service and social care services. Fragility fractures of the hip in the elderly are a substantial cause of mortality and morbidity. Revision surgery for any cause carries a higher morbidity, mortality, healthcare- and social economic burden. Which patients suffer failed surgery and the reasons for failure have not been established. The aim of this study was to determine which patients are at risk of failed proximal femoral fracture surgery, the mechanism and cause fo failed surgery and modifiable patient factors associated with failure of hip fracture surgery. From prospectively collected data of 795 consecutive proximal femoral fractures admitted between July 2007 and July 2008, all peri-operative and post-operative complications were identified. 55 (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age (p=0.01), smoking (p=0.01) and cannulated screw fixation (p<0.01). Cannulated screw fixation was associated with a 30.9% complication rate. Mechanical cause was the most common reason for cannulated screw failure. Hip hemiarthroplasty most commonly failed by infective causes. Inter-trochanteric and subtrochanteric fracture fixation had very low failure rates. Surgical complication was not found to be associated with an increased mortality but a post-operative medical complication (21.8%) was associated with higher rate of mortality at 4-years (78.5%) and shorter time to mortality. (Median time 0.16 years (95% CI 0.00–0.33)

To identify ideal screw placement for internal fixation of intra capsular fracture neck of femur to avoid fixation failures, 20 cadaveric bone measurements of the neck of femur in basal, midcervical and at sub capital regions were carried out using Vernial caliper and CT scan. Midcervical region of neck of femur measurements were further divided into upper half (Superior half) and Inferior half (Inferior Half). AP and Lateral view X-rays were obtained following three parallel screws placements in Femur neck:. Configuration 1: Triangular configuration where two screws are inferior and one superior. Configuration 2: Triangular configuration where two screws are placed superiorly and one screw inferiorly. Neck has wider diameter in the upper half of neck of femur than in the lower half in the mid cervical region. Placing two 7.0 mm cancellous screws (total 14 mm) in the lower half of the neck of femur, as widely practised, has more likely chances of not having purchase in the mid cervical region of the femur neck by at least one screw. Cannulated screws fixation carried out in reverse triangular configuration by placing two screws superiorly (superior-anterior and superior-posterior) and one screw inferiorly (inferior-central) has better fixation and avoids fixation failure. Reverse triangular configuration of fixation is also likely to support the weaker superior half of the neck which lacks stronger cortex and calcar part as in the inferior part of the neck. We also recommend placing a larger screw in the superior half of femur neck and a smaller screw in the inferior half in recon-–IM nail fixation, based upon our experiment result

There is still much debate on the appropriateness of taking post operative radiographs especially in the presence of high quality radiography that image intensifiers now provide. The aim of this study was to determine current UK practice regarding the use of check radiographs and to compare this practice with the implant related complications. A postal performa was sent to 450 randomly chosen UK Trauma and Orthopaedic Consultants to assess their practice regarding check radiographs following hip fracture surgery. In addition a case note review of all patients undergoing hip fracture surgery over the three years of 2001 to 2003 at Selly Oak Hospital, was performed. Patients undergoing revision surgery in the same admission were identified. The decision to revise was noted to determine whether check radiograph influenced the decision. Response rate to the performa was 66.7% (300/450). 96% routinely took postoperative radiographs following Hemiarthroplasty. Of these, 87% allowed the patient to mobilise before checking the radiograph. In the DHS group, 61% took check radiographs. Of these, 75% allowed the patient to mobilise prior to reviewing the radiograph. Following Cannulated screw fixation, 58% routinely performed check radiographs and 67% allowed the patient to mobilise before reviewing the radiograph. 1265 hip fracture surgeries were performed in our unit in three years. Only one decision to revise was based on a problem identified on a routine check radiograph. We highlight the lack of national consensus on the use of post operative radiographs. We recommend the use of post operative radiographs only when clinically indicated, hence sparing the patient from discomfort, unnecessary exposure to radiation as well as allowing more effective utilisation of radiological and human resources

Introduction. Following National patient safety alert on cement use in hip fracture surgery, we investigated the incidence and pattern of 72 hours peri-operative mortality after hip fracture surgery in a District General Hospital. Methods. We reviewed all patients who had hip fracture surgery between 2005-April, 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, peri-operative haemodynamic status, time and cause of death. Results. Over a 64 month period 15 cases were identified. Peri-operative death (PAD) was 1% (15/1402). 4/15 patients died intra-operatively. PAD was highest following Exeter Trauma Stem (ETS) implantation (5/85, 6%) and nil following Bipolar arthroplasty, Austin-Moore arthroplasty (AMA) or Cannulated screw fixation. PAD following total hip arthroplasty was 4% (1/25), Thompson's hemi-arthroplasty 2% (3/191), and Dynamic Hip Screw fixation 1% (6/695). Overall mortality after cemented implant was 2%. ETS implantation led to significantly increased peri-operative mortality compared to AMA (p=0.004). Operations were performed by both trainees (12) and Consultants (3). Both trainees (9) and Consultants (6) anaesthetised the patients. None of the patients belonged to ASA I or II (ASA III 6 and IV 9). All patients had significant cardio-vascular or pulmonary co-morbidity (Ca Lung 2, pulmonary fibrosis 1, end stage COAD 1, AF 6). Cemented implant insertion was followed by immediate haemodynamic collapse and death in 4/15, intra-operative haemodynamic instability in 1/15 and peri-operative instability in 5/15. Post-mortem was performed in 5/15: 2/5 were Pulmonary Embolism (PE), 2/5 bronchopneumonia and 1/5 Myocardial infarction (MI). 4/15 had suspected MI and 1/15 suspected PE. Conclusion. There was 1% risk of peri-operative death after hip fracture surgery. This risk was increased following cemented hemiarthroplasty and highest after ETS implantation. Risk was exacerbated in patients with pre-existing cardiovascular morbidity and independent of the seniority of the surgeon or the anaesthetist

Salvage Total Hip Arthroplasty (THA) presents a viable solution following failed treatment of a hip fracture. Several studies have suggested higher complication rate including high dislocation rate associated with salvage THA. The present study evaluates the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of a hip fracture and comparison made to Primary THA in osteoarthritis (OA). Between 1992 and 2007, 53 patients with a mean age of seventy years were treated with THA after the failed treatment of a hip fracture under the care of a single surgeon. The indication for conversion arthroplasty was Avascular necrosis head – 24(45.3%), screw cut out – 6 (11.3%), non-union – 2(3.8%), Displaced fracture – 2(3.8%), Secondary OA – 19 (35.8%). The implants retrieved were Cannulated screws – 3, Sliding plate and screw – 46, Spline plate – 2, Smith Petersons nail – 1, Martin Plate – 1. This group of patients were matched for age, sex, side, and ASA grading with a group of 59 patients who underwent THA for primary osteoarthritis (THA-OA group). Posterior approach was used in all cases. Four patients (7.5%) required grafting of cup and 21 patients (39.6%) required soft tissue release. The average blood loss was 555 ml, mean duration of surgery was 85.5 min, average inpatient stay was 6.7 days. Cemented THA was used in 43 patients and Cementless THA in 10 patients. At one year follow up there were no dislocations, one patient had an undisplaced femoral fracture treated in Spica. Three patients had broken screws; one patient with shortening > 1 inch. There was one revision for deep infection. The mean Harris Hip Score (HHS) improved from 28.4 to 82.5 at one year, while the Oxford Hip score (OHS) improved from 50.9 to 21.9 (Old system). When the scores were compared to the THA-OA group there was no difference in the oxford hip scores and the the mean one year HHS in the THA-OA group was slightly higher than the group with salvage THA, but the difference was not statistically significant. Hip arthroplasty is an effective salvage procedure in patients with prior surgery for hip fracture. Most patients have good pain relief and functional improvement. Despite the operative challenges, remarkably few serious orthopaedic complications were associated with this procedure in the present study

Cannulated screw fixation is currently the treatment of choice for slipped capital femoral epiphyses (SCFE). A SCFE module of the Bonedoc simulator was created in order to test the ability of advanced trainees to place the screw in the correct position, and the practicality of using the simulator within the orthopaedic surgery training curriculum. Bonedoc (University of Auckland) is a virtual reality simulator of image guided orthopaedic operations. 1. This simulator runs in Internet Explorer (Microsoft, USA) using the Octaga (Octaga, Norway) plugin. The total download is around 4 MB. The SCFE module was created from a CT scan of a Grade 2 acute on chronic SCFE. DICOM images were imported into 3DView (. www.rmrsystems.co.uk. ) and a mesh created. The generic femur from the DHS module was morphed within the CAD package Blender (Blender.org) to conform to this reconstructed SCFE mesh. Forty two advanced trainees operated on the same virtual SCFE during a training weekend. The trainees had 25 minutes to become familiar with the simulator and complete the operative case. The trainees performed all tasks relevant to the operation. At the operation’s conclusion the trainees self-assessed their performance. Subsequently the simulator provided surgically relevant objective feedback on aspects such as exact position of the screw, misplaced attempts and the number of x-rays. The results were analysed using SAS (SAS Institute, USA) in subgroups based on year on the scheme, as well as correlated within each operation. There was no difference in the accuracy with which the virtual slipped capital femoral epiphysis was pinned by trainees in different years in the training programme. However, 26 of the 39 of the virtual screws were placed in the superior direction. There was no correlation between number of X-ray images taken and final accuracy of screw placement. The number of misplaced drill holes was correlated both with number of X-ray images taken (p< 0.01) and operative time (p< 0.01) but not with final accuracy of the screw. An increase in misplaced attempts was correlated with angulation errors in the anterior plane (p< 0.01). There was no correlation between the trainees’ self assessment and any of the measured variables. The Bonedoc simulator provides a means to test trainees on technical aspects of a surgical procedure. It provides objective results, which can mimic real world outcomes. In addition, the ability to test all trainees on the same virtual operative case allows standardisation of assessment. All trainees completed the task to a similar level of accuracy, which may reflect the overall skill level in advanced trainees within the New Zealand. However, many trainees placed the screw in the superior portion of the femoral head, which is thought to increase the risk of avascular necrosis. 2. Further work is required to evaluate how accurately performance on the simulator predicts performance in the operating theatre