Aims. The surgical helmet system (SHS) was developed to reduce the risk of periprosthetic joint infection (PJI), but the evidence is contradictory, with some studies suggesting an increased risk of PJI due to potential leakage through the glove-gown interface (GGI) caused by its positive pressure. We assumed that SHS and glove exchange had an impact on the leakage via GGI. Methods. There were 404 arthroplasty simulations with fluorescent gel, in which SHS was used (H+) or not (H-), and GGI was sealed (S+) or not (S-), divided into four groups: H+S+, H+S-, H-S+, and H-S-, varying by exposure duration (15 to 60 minutes) and frequency of glove exchanges (0 to 6 times). The intensity of fluorescent leakage through GGI was quantified automatically with an image analysis software. The effect of the above factors on fluorescent leakage via GGI were compared and analyzed. Results. The leakage intensity increased with exposure duration and frequency of glove exchanges in all groups. When SHS was used and GGI was not sealed (H+S-), the leakage intensity via GGI had the fastest increase, consistently higher than other groups (H+S+, H-S+ and H-S-) after 30 minutes (p < 0.05) and when there were more than four instances of glove exchange (p < 0.05). Additionally, the leakage was strongly correlated with the duration of exposure (r. s. = 0.8379; p < 0.050) and the frequency of glove exchange (r. s. = 0.8198; p < 0.050) in H+S-. The correlations with duration and frequency turned weak when SHS was not used (H-) or GGI was sealed off (S+). Conclusion. Due to personal protection, SHS is recommended in arthroplasties. Meanwhile, it is strongly recommended to seal the GGI of the inner gloves and exchange the outer gloves hourly to reduce the risk of contamination from SHS. Cite this article: Bone Jt Open 2023;4(11):859–864

Aims. Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone. Methods. Overall, 31 patients with AO/OTA 31-A2 trochanteric fractures were randomized to either a SHS alone or a SHS with an additional TSP. To compare postoperative fracture motion, radiostereometric analysis (RSA) was performed before and after weightbearing, and then at four, eight, 12, 26, and 52 weeks. With the “after weightbearing” images as baseline, we calculated translations and rotations, including shortening and medialization of the femoral shaft. Results. Similar migration profiles were observed in all directions during the course of healing. At one year, eight patients in the SHS group and 12 patients in the TSP group were available for analysis, finding a clinically non-relevant, and statistically non-significant, difference in total translation of 1 mm (95% confidence interval -4.7 to 2.9) in favour of the TSP group. In line with the migration data, no significant differences in clinical outcomes were found. Conclusion. The TSP did not influence the course of healing or postoperative fracture motion compared to SHS alone. Based on our results, routine use of the TSP in AO/OTA 31-A2 trochanteric fractures cannot be recommended. The TSP has been shown, in biomechanical studies, to increase stability in sliding hip screw constructs in both unstable and intermediate stable trochanteric fractures, but the clinical evidence is limited. This study showed no advantage of the TSP in unstable (AO 31-A2) fractures in elderly patients when fracture movement was evaluated with radiostereometric analysis. Cite this article: Bone Jt Open 2024;5(1):37–45

Aims. The primary aim of this study was to compare surgical methods (sliding hip screw (SHS) vs intramedullary nailing (IMN)) for trochanteric hip fracture in relation to death within 120 days after surgery and return to independent living. The secondary aim was to assess whether the associations between surgical method and death or ability to return to independent living varied depending on fracture subtype or other patient characteristics. Methods. A total of 27,530 individuals from the Swedish Hip Fracture Register RIKSHÖFT (SHR) aged ≥ 70 years, admitted to hospital between 1 January 2014 and 31 December 2019 with trochanteric hip fracture, were included. Within this cohort, 12,041 individuals lived independently at baseline, had follow-up information in the SHR, and were thus investigated for return to independent living. Death within 120 days after surgery was analyzed using Cox regression with SHS as reference and adjusted for age and fracture type. Return to independent living was analyzed using logistic regression adjusted for age and fracture type. Analyses were repeated after stratification by fracture type, age, and sex. Results. Overall, 2,171 patients (18%) who were operated with SHS and 2,704 patients (18%) who were operated with IMN died within 120 days after surgery. Adjusted Cox regression revealed no difference in death within 120 days for the whole group (hazard ratio 0.97 (95% CI 0.91 to 1.03)), nor after stratification by fracture type. In total, 3,714 (66%) patients who were operated with SHS and 4,147 (64%) patients who were operated with IMN had returned to independent living at follow-up. There was no significant difference in return to independent living for the whole group (odds ratio 0.95 (95% CI 0.87 to 1.03)), nor after stratification by fracture type. Conclusion. No overall difference was observed in death within 120 days or return to independent living following surgery for trochanteric hip fracture, depending on surgical method (SHS vs IMN) in this recent Swedish cohort, but there was a suggested benefit for SHS in subgroups of patients. Cite this article: Bone Jt Open 2024;5(10):843–850

Aims. This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality. Methods. This retrospective study included ITF patients aged 50 years and over treated with SHS fixation between 2019 and 2021 at a major trauma centre. Demographic information, fracture type, delirium status, American Society of Anesthesiologists grade, and length of stay were collected. LWT and tip apex distance were measured. Revision surgery and mortality were recorded at a mean follow-up of 19.5 months (1.6 to 48). Cox regression was performed to evaluate independent risk factors associated with revision surgery and mortality. Results. The cohort consisted of 890 patients with a mean age of 82 years (SD 10.2). Mean LWT was 27.0 mm (SD 8.6), and there were 213 patients (23.9%) with LWT < 20.5 mm. Overall, 20 patients (2.2%) underwent a revision surgery following SHS fixation. Adjusting for covariates, LWT < 20.5 mm was not independently associated with an increased revision or mortality risk. However, factors that were significantly more prevalent in LWT < 20.5 mm group, which included residence in care home (hazard ratio (HR) 1.84; p < 0.001) or hospital (HR 1.65; p = 0.005), and delirium (HR 1.32; p = 0.026), were independently associated with an increased mortality risk. The only independent factor associated with increased risk of revision was older age (HR 1.07; p = 0.030). Conclusion. LWT was not associated with risk of revision surgery in patients with an ITF fixed with a SHS when the calcar was intact, after adjusting for the independent effect of age. Although LWT < 20.5 mm was not an independent risk factor for mortality, patients with LWT < 20.5 mm were more likely to be from care home or hospital and have delirium on admission, which were associated with a higher mortality rate. Cite this article: Bone Jt Open 2024;5(2):123–131

Aims. Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines. Methods. We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use. Results. We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres. Conclusion. Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity. Cite this article: Bone Jt Open 2022;3(10):741–745

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies. A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance. 13638 records were included (72% female). 9867 received a SHS (72%). No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's. There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations. Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS. Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted

Aims. Evaluate if treating an unstable femoral neck fracture with a locking plate and spring-loaded telescoping screw system would improve construct stability compared to gold standard treatment methods. Methods. A 31B2 Pauwels’ type III osteotomy with additional posterior wedge was cut into 30 fresh-frozen femur cadavers implanted with either: three cannulated screws in an inverted triangle configuration (CS), a sliding hip screw and anti-rotation screw (SHS), or a locking plate system with spring-loaded telescoping screws (LP). Dynamic cyclic compressive testing representative of walking with increasing weight-bearing was applied until failure was observed. Loss of fracture reduction was recorded using a high-resolution optical motion tracking system. Results. LP constructs demonstrated the highest mean values for initial stiffness and failure load. LP and SHS constructs survived on mean over 50% more cycles and to loads 450 N higher than CS. During the early stages of cyclic loading, mean varus collapse of the femoral head was 0.5° (SD 0.8°) for LP, 0.7° (SD 0.7°) for SHS, and 1.9° (SD 2.3°) for CS (p = 0.071). At 30,000 cycles (1,050 N) mean femoral neck shortening was 1.8 mm (SD 1.9) for LP, 2.0 mm (SD 0.9) for SHS, and 3.2 mm (SD 2.5) for CS (p = 0.262). Mean leg shortening at construct failure was 4.9 mm (SD 2.7) for LP, 8.9 mm (SD 3.2) for SHS, and 7.0 mm (SD 4.3) for CS (p = 0.046). Conclusion. Use of the LP system provided similar (hip screw) or better (cannulated screws) biomechanical performance as the current gold standard methods suggesting that the LP system could be a promising alternative for the treatment of unstable fractures of the femoral neck. Cite this article: Bone Joint Res 2020;9(6):314–321

Aims. Surgical treatment of hip fracture is challenging; the bone is porotic and fixation failure can be catastrophic. Novel implants are available which may yield superior clinical outcomes. This study compared the clinical effectiveness of the novel X-Bolt Hip System (XHS) with the sliding hip screw (SHS) for the treatment of fragility hip fractures. Methods. We conducted a multicentre, superiority, randomized controlled trial. Patients aged 60 years and older with a trochanteric hip fracture were recruited in ten acute UK NHS hospitals. Participants were randomly allocated to fixation of their fracture with XHS or SHS. A total of 1,128 participants were randomized with 564 participants allocated to each group. Participants and outcome assessors were blind to treatment allocation. The primary outcome was the EuroQol five-dimension five-level health status (EQ-5D-5L) utility at four months. The minimum clinically important difference in utility was pre-specified at 0.075. Secondary outcomes were EQ-5D-5L utility at 12 months, mortality, residential status, mobility, revision surgery, and radiological measures. Results. Overall, 437 and 443 participants were analyzed in the primary intention-to-treat analysis in XHS and SHS treatment groups respectively. There was a mean difference of 0.029 in adjusted utility index in favour of XHS with no evidence of a difference between treatment groups (95% confidence interval -0.013 to 0.070; p = 0.175). There was no evidence of any differences between treatment groups in any of the secondary outcomes. The pattern and overall risk of adverse events associated with both treatments was similar. Conclusion. Any difference in four-month health-related quality of life between the XHS and SHS is small and not clinically important. There was no evidence of a difference in the safety profile of the two treatments; both were associated with lower risks of revision surgery than previously reported. Cite this article: Bone Joint J 2021;103-B(2):256–263

Increasing incidence of osteoporosis, obesity and an aging population have led to an increase in low energy hip fractures in the elderly. Perceived lower blood loss and lower surgical time, media coverage of minimal invasive surgery and patient expectations unsurprisingly have led to a trend towards intramedullary devices for fixation of extracapsular hip fractures. This is contrary to the Cochrane review of random controlled trials of intramedullary vs extramedullary implants which continues recommends the use of a sliding hip screw (SHS) over other devices. Furthermore, despite published literature of minimally invasive surgery (MIS) of SHS citing benefits such as reduced soft tissue trauma, smaller scar, faster recovery, reduced blood loss, reduced analgesia needs; the uptake of these approaches has been poor. We describe a novel technique one which remains minimally invasive, that not only has a simple learning curve but easily reproducible results. All patients who underwent MIS SHS fixation of extracapsular fractures were included in this study. Technique is shown in Figure 1. We collated data on all intertrochanteric hip fractures that were treated by a single surgeon series during period Jan 2014 to July 2015. Data was collected from electronic patient records and radiographs from Picture Archiving and Communication System (PACS). Surgical time, fluoroscopy time, blood loss, surgical incision length, post-operative transfusion, Tip Apex Distance (TAD) were analyzed. There were 10 patients in this study. All fractures were Orthopaedic Trauma Association (OTA) type A1 or A2. Median surgical time was 36 minutes (25–54). Mean fluoroscopy time was similar to standard incision sliding hip screw fixation. Blood loss estimation with MIS SHS can be undertaken safely and expeditiously for extracapsular hip fractures

Objectives. The Sliding Hip Screw (SHS) is commonly used to treat trochanteric hip fractures. Fixation failure is a devastating complication requiring complex revision surgery. One mode of fixation failure is lag screw cut-out which is greatest in unstable fracture patterns and when the tip-apex distance of the lag screw is > 25 mm. The X-Bolt Dynamic Hip Plating System (X-Bolt Orthopaedics, Dublin, Ireland) is a new device which aims to reduce this risk of cut-out. However, some surgeons have reported difficulty minimising the tip-apex distance with subsequent concerns that this may lead to an increased risk of cut-out. Patients and Methods. We measured the tip-apex distance from the intra-operative radiographs of 93 unstable trochanteric hip fractures enrolled in a randomised controlled trial (Warwick Hip Trauma Evaluation, WHiTE One trial). Participants were treated with either the sliding hip screw or the X-Bolt dynamic hip plating system. We also recorded the incidence of cut-out in both groups, at a median follow-up time of 17 months. Results. There was a significantly increased tip-apex distance with the use of the X-Bolt (mean difference 3.7mm (95% confidence interval 1.58 to 5.73); SHS mean 17.1 mm, X-Bolt mean 20.8; p = 0.001. However, this was not associated with an increased incidence of cut-out at a median follow-up time of 17 months, with three cut-outs (6%) in the SHS group and 0 (0%) in the X-Bolt group. Conclusion. The X-Bolt is a safe implant with no increased risk for cut-out. Concerns about minimising the tip-apex distance may be justified but do not appear to be clinically important. Cite this article: M. A. Fernandez, A. Aquilina, J. Achten, N. Parsons, M. L. Costa, X. L. Griffin. The tip-apex distance in the X-Bolt dynamic plating system. Bone Joint Res 2017;6:–207. DOI: 10.1302/2046-3758.64.BJR-2015-0016.R2

Background. Intracapsular neck of femur fractures are one of the most common injuries seen in Orthopaedics. When the fracture is amenable to internal fixation there are 2 main treatment options, namely multiple cannulated hip screws (MCS) and 2-hole sliding hip screws (SHS). In this retrospective study we examine the outcomes associated with these two methods of internal fixation. At present there is little consensus regarding which treatment should be used. Methods. 161 patients were found to have suffered intracapsular neck of femur fracture treated with either SHS or MCS fixation over a 5 year period from April 2009 to April 2014, allowing at least 1 year follow up following injury. The patients imaging and clinical notes were then reviewed to ascertain the outcome of their treatment and any complications. Results. 93 patients were treated with a sliding hip screw compared to 68 that had been treated with cannulated screws. To ensure the fractures in each group were comparable in terms of fracture severity they were classified using gardens and pauwels score. The mean age of the group treated with SHS was 75.15 years, 7.69 years higher than those treated with MCS. The mean length of inpatient stay was 4.7 days longer for patients treated with sliding hip screws than those treated with cannulated screws, which is significantly more than would be predicted by age difference alone. Further patients were excluded for analysis of failure rate if they had not been sufficiently followed up, leaving 122 patients, 58 treated with MCS and 64 with SHS. A significantly higher (p=0.0136) proportion of patients treated with SHS (32%) suffered failure of their fixation compared to those treated with MCS (10%). The SHS group was further classified by whether or not a permanent derotation screw was employed. The use of a derotation screw provided protection against failure with a number needed to treat of 3.82, decreasing the failure rate to 14% which was not significantly more than the failure rate for MCS. Conclusions. We recommend that the first choice treatment for intracapsular neck of femur fractures amenable to internal fixation should be cannulated screws due to a lower rate of failure and shorter length of inpatient stay. If a surgeon has a strong preference for sliding hip screw we strongly recommend inserting a permanent derotation screw

Aims

Congenital pseudarthrosis of the tibia (CPT) has traditionally been a difficult condition to treat, with high complication rates, including nonunion, refractures, malalignment, and leg length discrepancy. Surgical approaches to treatment of CPT include intramedullary rodding, external fixation, combined intramedullary rodding and external fixation, vascularized fibular graft, and most recently cross-union. The current study aims to compare the outcomes and complication rates of cross-union versus other surgical approaches as an index surgery for the management of CPT. Our hypothesis was that a good index surgery for CPT achieves union and minimizes complications such as refractures and limb length discrepancy.

Introduction: Hip fractures are a massive problem in an ageing population with 7–21 million predicted world-wide by 2025. The stabilization of intertrochanteric fractures reduces morbidity, mortality and allows mobilization. The treatment of these fractures has evolved over the past 50 years to the Sliding hip screw and plate, and intramedullary devices Current evidence suggests that the SHS systems are superior in stable fracture patterns and intramedullary devices are superior in unstable fracture patterns such as reverse oblique fractures or subtrochanteric fractures. Accurate implant positioning will prevent failure and the associated morbidity and mortality. The most frequent failure is due to cut out of the screw through the femoral head due to poor positioning. Cut out is directly correlated with tip apex distance (TAD). A TAD < 25mm has been to shown to be key to preventing cut out irrespective of fixation device. Aims: The aims of this audit were to review TAD in proximal femoral fractures stabilized with a SHS system at one hospital to ensure:. TAD is < 25mm. To establish whether there was a correlation between TAD and surgeon grade or fracture type. To establish positions of screws on both radio graphs. To ensure SHS are used in the correct fracture types. Results: Radiographs over a period of 1 year where reviewed. There were 86 cases of SHS fixation. 72% of cases were female (62:24). The mean age was 84(65 to 97). The mean preoperative delay before surgery was 4.5 range (0 –15). 13% of cases (11/86) had no postoperative radiographs either digitally or hard copies stored in the notes. The mean value of TAD was 20.8mm (Std dev 6.89). There was no correlation between fracture patterns and TAD, or surgeon grade and TAD. However there was a trend for higher TAD in inexperienced surgeons and in more complex fracture patterns. The majority of cases were operated on by Registrars 67%, Staff grade 15%, Research fellows 9%, SHOs 6% and Consultant grades 3%. Registrars achieved Centre–Centre positions in 62% of cases with staff grade 47% of cases. The majority of SHS were performed for Types 2 and 4 according to Jensen & Michaelson classification. SHS implants were used in one subtrochanteric fracture and zero reverse oblique fractures. 21 cases had a TAD> 25mm and one of these has gone on to failure, requiring THR. Conclusion: The mean TAD was within recommendations and there was no correlation between surgeon grade, fracture pattern and TAD. The positioning of screws corresponds closely to published data and remains acceptable as does the use of SHS devices. Both the preoperative delay and number of inadequate radiographs is unacceptable and needs improvement

Introduction. The treatment of trochanteric and subtrochanteric fractures remains controversial, and new implants are constantly being developed trying to improve outcome and minimize the number of complications in these fractures. In Norway the Sliding Hip Screw(SHS), with or without a Trochanteric Stabilizing Plate (TSP), is still the most commonly used implant, but worldwide nailing of these fractures is increasing. This trend, however, has not been supported by documentation of better clinical results compared to the SHS in well designed studies. Therefore, in the present study we compared the recently launched Trigen Intertan nail (Smith and Nephew) with the SHS in the treatment of trochanteric and subtrochanteric fractures. Patients and Methods. In a prospective, randomized multicenter study with 697 patients, we compared the Trigen Intertan nail with the SHS regarding postoperative pain, functional mobility, complications, and reoperation rates. Patients older than 60 years with trochanteric and subtrochanteric fractures were included in 5 hospitals. At day 5, and 3 and 12 months postoperatively, pain was measured using a Visual Analogue Scale (VAS), and the Timed Up and Go-test (TUG-test) was performed to evaluate functional mobility. Complications and reoperations were recorded at discharge, and after 3 and 12 months. Results. 328 patients were evaluated at day 5 postoperatively. At mobilization patients treated with the nail had less pain compared to the SHS (VAS 47 vs. 53, p=0.02). Still, a difference of 6 points may not be of clinical significance. There was no difference in pain at rest or in early functional mobility. The length of postoperative hospital stay was also similar for the two groups (8.5 and 8.4 days respectively). At 3 (457 patients) and 12 months (374 patients) there was no difference in pain or TUG-test performance. At discharge, and after 3 and 12 months the overall reoperation rate for the groups was similar, and there was no difference regarding general complications. The results were comparable for the two groups, regardless of fracture classification (stable or unstable fractures). However, postoperative femoral fractures still seems to be an issue even with modern nails. 5 postoperative femoral fractures were encountered in the Intertan group, whereas 1 occurred in the SHS-group. Conclusion. Overall, there was no major difference in the results for the Intertan nail and the SHS in our study. Both methods provided predictable and good results in the treatment of trochanteric and subtrochanteric fractures. We found however less pain at mobilization for patients operated with a nail at day 5 postoperatively compared to the SHS. No difference in pain or function was evident at any later follow up. There was no difference in reoperation rates between the groups, but more postoperative ipsilateral femoral fractures occurred in the Intertan group. The clinical results in this study do not support the trend towards more nailing of trochanteric and subtrochanteric fractures

Femoral head collapse is a possible complication after surgical treatment of femoral neck fractures. The purpose of this study was to examine whether implantation of a Sliding Hip Screw (SHS) or an X-Bolt could increase the risk of femoral head collapse. Similar to traditional hip screws, the X-Bolt is implanted through the femoral neck; however, it uses an expanding cross-shape to improve rotational stability. The risk of collapse was investigated alongside patient factors, such as osteonecrosis. This numerical study assessed the risk of femoral head collapse using linear eigenvalue buckling (an established method [1]), and also from the maximum von Mises stress within the cortical bone. The femoral head was loaded using the pressures reported by Yoshida et al. for a patient sitting down (reported to put the femoral head at greatest risk of collapse [2]), with a peak pressure of 9.4 MPa and an average pressure of 1.59 MPa. The femur was fixed in all degrees of freedom at a plane through the femoral neck. The X-Bolt and SHS were implanted in accordance with the operative techniques. The femoral head and implants were meshed with quadratic tetrahedral elements, and cortical bone was meshed with triangular thin shell elements. A converged mesh seeding density of 1.2 mm was used. All models were create and solved using ABAQUS finite element software (version 6.12, Simulia, Dassault Systèmes, France). The influence of implant type and presence was examined alongside a variety of patient factors:. Osteonecrosis, modelled as a cone of bone of varying angle, and varying modulus values. Cortical thinning. Reduced cortical modulus. Femoral head size. Twenty-two finite element models were run for each implant condition (intact; implanted with the X-Bolt; implanted with a SHS), resulting in a total of 66 models. The finite element models were validated using experimental tests performed on five 4. th. generation composite Sawbones femurs (Malmö, Sweden), and verified against previously published results [1]. No significant difference was found between the X-Bolt and the SHS, for either critical buckling pressure (p=0.964), or the maximum von Mises stress (p=0.274), indicating no difference in the risk of femoral head collapse. The maximum von Mises stress (and therefore the risk of collapse) within the cortical bone was significantly higher for the intact femoral head compared to both implants (X-Bolt: p=0.048, SHS: p=0.002). Of the factors examined, necrosis of the femoral head caused the greatest increase in risk. The study by Volokh et al. [1] concluded that deterioration of the cancellous bone underneath the cortical shell can greatly increase the risk of femoral head collapse, and the results of the present study support this finding. Interestingly the presence of either an X-Bolt or SHS implant appeared to reduce the risk of femoral head collapse

Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification A3 fractures) are known to have an increased risk of fixation failure. 58 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon PF nail) or a sliding hip screw (SHS). The mean age of the patients was 82 and 11% were male. All patients were followed up for one year by a research nurse blinded to the treatment groups. Mean length of surgery was 50 minutes for the nail versus 52 minutes for the SHS. There were no differences between groups in the need for blood transfusion. Operative complications tended to be less for the nail group (1/27 versus 5/26). Mean hospital stay was 18 days for the nail group versus 29 days for those treated with the SHS. The only fracture healing complications were one case of cut-out in the SHS group and two cut-outs in the nail group, two of which required revision surgery. During follow-up those patients treated with the nail reported a tendency to lower pain scores than those treated with the SHS (p=0.04 at two months). This difference persisted even at one year from injury. Mortality and regain of mobility was similar between groups. These results indicate that for these difficult fractures types both types of fixation produce comparable outcomes

The goal of this study was to develop and validate a short, evaluative self-report questionnaire for the clinical self-assessment of patients with hip osteoarthritis (OA). If used together with other self-report outcome tools (e.g. generic or physical activity measures), such a short joint-specific questionnaire could avoid an increased burden to the patients and decrease the risk of data loss. All items of the new score (Schulthess Hip Score, SHS) were generated solely on patient perceptions, for item removal we used the clinical severity-importance rating and inter-item correlation methods. The final score consisted of only five items. We then assessed the following metric properties of the SHS in 105 consecutive patients with symptomatic hip OA (mean age, 63.4 ± 11 years, 48 women) undergoing total hip arthroplasty (THA) in our clinic: proportion of evaluable questionnaires, reproducibility, internal consistency, concurrent validity, and responsiveness. 97% of the questionnaires were evaluable. Reproducibility of the SHS was excellent (intraclass correlation coefficient (ICC) 0.90; standard error of the measure (SEM) 6.4). Exploratory factor analysis indicated that all items loaded on only 1 factor which accounted for 69.4% of the total variance. Cronbach’s alpha was 0.88. Evidence of convergent validity was provided by moderate to high correlations with scores and subscales of the WOMAC (r = 0.58–0.78), Oxford Hip Score (r = 0.78), Harris Hip Score (r = 0.37), SF-12 physical component scale (r = 0.57), UCLA activity scale (r = 0.48), and Tegner score (r = 0.53). Evidence of divergent validity was provided by a lower correlation with the SF-12 mental component scale (r = 0.37). The SHS proved to be responsive with an effect size (ES) of 2.15 and a standard response mean (SRM) of 1.74 six months after THA. Taken together, the results of this study provide evidence to support the use of the five-item self-report SHS in patients with hip osteoarthritis. Considering the brevity of this score, it could be easily used together with other measures such as generic and physical activity assessment tools, without overburdening patients with an inordinate number of items and questions

Background: The treatment of trochanteric and subtrochanteric fractures is still controversial. In Norway the most commonly used implant for these fractures is the Sliding Hip Screw (SHS), with or without a trochanteric support plate. The Intertan nail (Smith & Nephew) has been launched as a nail with improved biomechanical properties for the treatment of these fractures, but so far it has not been shown that the clinical results are superior to the traditional Sliding Hip Screw. We wanted to investigate any differences in pain and function between the new Intertan nail and the Sliding Hip Screw in the early postoperative phase. Materials and Methods: 665 patients older than 60 years with a trochanteric or subtrochanteric fracture were randomized to either a SHS (CHS/DHS) or an Intertan nail in 5 hospitals. For practical reasons only 315 patients (47%) were evaluated at day 5 postoperatively (163 Intertan and 152 SHS), and these patients were used for our analysis. Pain was measured using a Visual Analog Scale (VAS), and early functional mobility by the “Timed Up and Go”- test (TUG-test). T-tests and chi-square tests were used to examine differences between the groups. Results: The average pain at rest was similar for the 2 groups (VAS 21). Pain at mobilization, however, differed, where patients operated with the Intertan nail had less pain than those operated with the SHS (VAS 47 vs. 53, p = 0.02). The difference between the implants was most pronounced for the simple two-part fractures (AO Type A1). More patients treated with the nail than with the SHS performed the TUG-test at day 5 (85/163 vs. 63/152, p = 0.06), but there was no statistically significant difference regarding the average speed the TUG-test was performed with (71 vs. 66sec, p = 0.36). The implant type did not influence the length of hospital stay. Discussion/Conclusion: Regarding early postoperative pain and function, there seems to be similar or better results for trochanteric and subtrochanteric fractures treated with the Intertan nail compared to the SHS. The difference in measured pain level was statistically significant, but may not be clinically significant (a difference of VAS 6). We could not detect any significant differences in terms of early functional mobility between the two implants. In our opinion it still remains to show good long-term results and acceptable complication rates before the new Intertan nail is widely taken into use. Due to the additional costs for the Intertan nail also economic aspects should be considered when choosing the implant and operative method for these fractures

Background: Reverse obliquity and transverse fractures of the proximal femur represent a distinct fracture pattern in which the mechanical forces displace the femur medially thus increasing the risk of fixation failure. There is a paucity of published literature in this area of trauma. This study constitutes the largest series of such fractures. Methods: Using the hip fracture registry at this institution 101 reverse obliquity and transverse fracture patterns were identified from 3336 consecutive hip fractures. All surviving patients were followed up for 1 year. Results: Of 100 patients treated operatively, 59 were treated with 1350 sliding hip screws (SHS), 22 were treated with 1350 sliding hip screw devices designed to resist medialization (3 sliding hip screws with trochanteric plate and 19 Medoff plates), and 19 were treated with intramedullary sliding hip screw devices (1 short Gamma nail, 9 long Gamma nails, 6 Reconstruction nails, 6 long Targon nails, 1 short Targon nail). The SHS had 4 failures (6.8%), and the intramedullary devices one failure (5.3%). Those extramedullary devices augmented to prevent medialization had higher failure rates (1 of 3 SHS with trochanteric plate and 3 of 19 Medoff plates), with combined failure rate of 15.8%. Conclusion: The 1350 SHS and the intramedullary devices had similar failure rates of 6.8% and 5.2% respectively. Those extramedullary devices designed to prevent medialization had higher failure rates (combined failure rate of 4/22 or 18%). This is similar to the high failure rate in 950 devices reported elsewhere. This suggests that extramedullary devices attempting to combat the difficult biomechanics of these fractures are unsuccessful. Better results can be obtained by using the standard 1350 SHS or with intramedullary sliding hip screw devices

Introduction A procedure of selective musculo-tendinous lengthenings is presented as treatment for chronic lateral elbow pain. The rationale for surgery is to decrease tensile force at the lateral epicondyle and simultaneously reduce posterior interosseous nerve compression in the radial tunnel. This study presents biomechanical and clinical data on this surgical technique. Methods In a human cadaver study, force transducer measurements were made in the common extensor tendon, and after sequential tensioning of the muscles arising from the lateral epicondyle. In a separate cadaver study, a balloon catheter measured pressure in the radial tunnel after sequential musculo-tendinous lengthening of the forearm extensor muscles. A preliminary clinical study was performed on 12 subjects (13 elbows). All had failed extensive conservative treatment and subsequently underwent combined musculo-tendinous lengthening of ECRB, EDC, and superficial head of supinator (SHS). In the clinical series, 75% of subjects were involved in Work Cover claims. Clinical outcomes in this small series were reviewed. Results ECRB and EDC tensioning produced the largest force transducer measurements in the common extensor tendon at the lateral epicondyle. SHS increased force transducer measurements moderately, suggesting this muscle may also contribute to the clinical syndrome of lateral epicondylitis. ECRL and ECU tensioning lead to non significant increases in force transducer measurements. Radial tunnel pressure dropped substantially (77%) after musculo-tendinous lengthening of SHS. Lengthening of other forearm extensors had little effect on measured radial tunnel pressure. All subjects recorded improvement in visual analogue pain scores, with post-operative scores between zero and two. Grip strength was preserved or improved. By the criteria of Roles and Maudsley, nine elbows were excellent, two good, one fair and one poor. Overall 11 of the 12 subjects reported they would have the procedure again. Conclusions This study demonstrates a biomechanical basis for SHS in the aetiology of lateral epicondylitis and radial tunnel syndrome, and supports a combined musculo-tendinous lengthening of ECRB, EDC, and SHS in the treatment of chronic lateral elbow pain. Satisfactory clinical results are reported in this group of patients including those involved in Work Cover claims